tag:blogger.com,1999:blog-73901433713992167332024-03-06T12:02:15.288-08:00Heard in the ORA blog that features articles on a variety of subjects, all from the perspective of a busy practicing General Surgeon who also happens to be an author. Topics range from varying aspects of healthcare and surgery to animals; sometimes humorous, sometimes serious, but always entertaining and informativeDavid Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.comBlogger166125tag:blogger.com,1999:blog-7390143371399216733.post-30295539365589911842020-02-01T13:17:00.003-08:002020-02-01T13:17:58.520-08:00<br />
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">With all the concerns about the Corona Virus I’ve
developed the following short questionnaire to keep us safe during this
difficult time.<o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Health Questionnaire<o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Have you been out of the United States in the last 90
days?<span style="mso-spacerun: yes;"> </span>Y___<span style="mso-spacerun: yes;"> </span>N___<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Have you been
to Mainland China in the <o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span>last 180
days?<span style="mso-tab-count: 8;"> </span>Y___
N___<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Have you been to an airport in the last 90 days?<span style="mso-tab-count: 2;"> </span><span style="mso-spacerun: yes;"> </span>Y___<span style="mso-spacerun: yes;"> </span>N___<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Have you been in a room with more than ten people<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span>In the last
60 days?<span style="mso-tab-count: 7;"> </span>Y___
N___<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Have you been inside the Loop?<span style="mso-tab-count: 5;"> </span>Y___ N___<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Have ever seen the movie “Mulan”?<span style="mso-tab-count: 5;"> </span>Y___
N___ <o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Have you eaten Moo Shu Pork, Moo Goo Gai Pan,<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> Won Ton Soup, any Lo Mein, General Tsao’s Chicken or<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> an egg roll in the last 90 days?<span style="mso-tab-count: 6;"> </span>Y___
N___<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Do you drink Corona beer?<span style="mso-tab-count: 6;"> </span>Y___ N___<o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">If any answer is yes please refrain from greeting me
or acknowledging my presence. If you must interact then a surgical mask is the
minimum requirement. Certainly no direct physical contact is allowed.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Thank you for respecting my concerns.<o:p></o:p></span></div>
<br />David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-7082050235936736492018-03-03T12:08:00.002-08:002018-03-03T12:08:30.615-08:0059 Minutes<br />
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><span style="mso-tab-count: 2;"> </span></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Four
O one? I have to get up in fifty nine minutes,” I groaned<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
was still dark. There was only a faint glow from the clock.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
stared up at the gloom of the early morning.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I
can’t do it,” I thought. “Face another day of “good mornings, how <b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;">are </i></b>you
doing<b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;">?
Are you OK? …Can I do anything</i></b>?”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
flipped the pillow around to avoid the damp spot. I turned on the music. The Complete
Simon and Garfunkel began to play randomly.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Hello darkness my old friend<o:p></o:p></span></i></div>
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<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I’ve come to talk with you again…<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">How
true, Mr. Simon. That’s all that’s left for me. Darkness. It’s all I’ve felt
for weeks now. She died exactly nine weeks ago today. That was the day darkness
descended. And, I could have prevented it. I should have taken it more
seriously.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">...<i style="mso-bidi-font-style: normal;">and whispered in the sounds of silence.<o:p></o:p></i></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
took a sip from the glass perched on the dresser next to my bed. The water was
still cold as I felt the sticky cottony feeling wash away with the soothing coolness
which bathed my throat. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
wish that water could wash away all my memories.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
pulled open the top drawer and flipped on the light. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“If
things get too overwhelming take one of these,” George said. “It’ll take the
edge off.”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">George
was a good friend and a pretty good Internist. And smart, he only gave me
twenty pills. Not enough…not enough to do the job.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“…he turned on the gas and he went to
sleep<o:p></o:p></span></i></div>
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<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">With the windows closed so he’d never
wake up…”<o:p></o:p></span></i></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Isolated,
alone. I feel like that “Most Peculiar Man.” Maybe his way will work. Not gas,
though, too dangerous. Too much potential to hurt someone else if there was an
explosion. But maybe the car in a locked garage. Should be fairly painless.
Maybe a little coughing. Take a few of those pills, start the car, go to sleep
and …the end.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“<i style="mso-bidi-font-style: normal;">Richard Cory went home last night<o:p></o:p></i></span></div>
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<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">And put a bullet through his head.”<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">That
would work, if I owned a gun. Too messy, maybe? Of course I’d be dead, so who
cares? But I don’t own a gun. Besides, with my luck I’d probably miss and blow
off half my face and have to live the rest of my life breathing through my neck
and being fed through a tube. <o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">There’s
something wrong with me, I thought. Quite an understatement.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
suppose, being a surgeon, the best way would be to slash my arm. At least I
know how to do it. Fill up the tub with hot water, take a scalpel and cut the
brachial artery longitudinally. <o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Use
a little topical Lidocaine and it would be quick, fairly painless and
effective.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
remember that patient, the one who broke a window to rob somebody’s home. Came
in with BP of forty over zero. And, all he had was a little laceration on his
arm, right in the middle of the antecubital fossa, maybe one and a half
centimeters. But that window did its damage. The hole in the artery was also
one and half centimeters. Later on the police told me there was blood sprayed
all over the ceiling and walls, almost like he was trying to create some form
of art using his arterial spray. Alan, that was his name; not the brightest
thief I’ve ever met.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
fumbled around in my nightstand and pulled out a #10 scalpel, still wrapped in
its sterile bag. It gleamed in the pale light, beckoning, almost imploring me
to release it from its plastic bondage.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I
could do it right now.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
lay back and put my hand under the pillow, still clutching the sterile lifeless
blade.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe
it would be for the best? After all, do I really do anything good? Oh, sure,
suck out gallbladders left and right. Big deal. If I’m not around, there are
still half a dozen competent surgeons in the area capable of doing the job;
well one or two anyway.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“August, die she must<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The autumn wind blows chilly and cold<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">September, I remember<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">A love once new has now grown old.”<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
hasn’t grown old, it’s dead. No more love. No more romance. No hope. No more
anything. Just loneliness and sadness intermingled with a few hours escape at
work. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“What’s
that laugh?” I said out loud. But I knew who it was. It was her laugh.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
flipped on to my back and held the scalpel in front of my face and then swiped
the plastic against my arm. The laugh grew louder.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Please,
don’t do that. I’m sorry…so sorry,” I screamed out loud.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">And
there she was. Her long brown hair hung below her shoulders, just reaching the
top of her breasts. She opened her mouth as if to speak, but then closed it,
smiled for a moment as I reached out to touch her silky hair. The vision faded
away, leaving only the silhouette of the scalpel, still safely wrapped in its
plastic cocoon.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“What’s
the point?” I thought.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“What
about last Monday? That gunshot wound to the abdomen. If you hadn’t been there
he never would have made it.” I stated this out loud, challenging myself.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Is
this what it’s come to? Asking myself rhetorical questions? Ok, I did save Mr.
Cortez’s life. But, to what end? How did he get shot? <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Was
it really the proverbial two dudes that came by and shot him while he was
sitting on his porch reading the bible? At three am?<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
let the knife fall to the floor.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Why
did I have to say, “Oh, it’s just a little cough, probably a virus, it should
go away. Why didn’t I get a chest X-ray? We could have found the tumor months
earlier and it would have made a difference. I know it. And how you suffered.
Pain with every breath, violent coughing, so many moments of sheer panic as you
vainly tried to take in enough oxygen. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">How
can I forget that mask of impending death. Sunken cheeks, dark hollow eyes,
blue lips, the rasp with every … How can I ever find forgiveness?<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Meow,
meow.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
looked up and saw Midnight staring at me from the foot of the bed. Her black
cat.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I
hate cats,” I’d remarked when she walked into the kitchen clutching the little
black kitten to her chest.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You’ll
get used to him,” she replied. “He won’t be much work. Don’t worry, I’ll empty
the litter box.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">And
she did. I got used to him, sort of. I guess we tolerated each other.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
looked at him as he eyed me from a safe distance.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You
miss her, too? Don’t look at me with those angry, accusatory eyes. Haven’t I
been feeding you?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span>“I know I’m fakin’ it<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Not really making it.”<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
guess “just feeding you” isn’t enough. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Am
I supposed to play with you? Cuddle you? Whisper sweet nothings into your black
ears?” I asked softly. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Midnight
stared back at me, then jumped off the bed. I got up to look for him, something
I’d never done before.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I
have to get up in a few minutes anyway,” I muttered.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
stopped and looked out of the window at the dark, clear early morning sky.
Stars twinkled down at me. I saw a particularly bright star.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Probably
Jupiter. No, Jupiter should be over to the right. Maybe it’s her staring down
from heaven; looking after me. She would do that. She always cared more about
me, more than herself. How many times did I laugh at her silly thoughts, how
many times did I dismiss her worries, her fears. Why did I pooh pooh her God.
Well, if her God is up there, she’s with him now. Happy, I hope.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
stared into the dark early morning sky.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“It’s
not fair. You should have taken me,” I almost screamed, staring out at the
early morning sky.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span>What I wouldn’t give to see her lying next to
me right now?<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Hallelujah, Go tell it on a mountain<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Over the Hills and everywhere<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Go tell it on a Mountain<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Jesus Christ is born”</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Is
that really Simon and Garfunkel? I guess they did sing that song. It was on the
album Wednesday Morning 3 AM.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Midnight
jumped up on the window sill and into my arms. He pushed his head into my
chest. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“What’s
gotten into you, cat? All of a sudden, you’re not treating me like I’ve got
feline plague?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Meow,”
he answered.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Is
that all you can say?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">He
licked my hand with his rough tongue.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I
know, I know. I miss her, too.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Down in a lowly manger<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Humble Christ was born<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">And God sent salvation<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">That Blessed Christmas morn”<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Midnight
stared into my eyes with a look I can’t explain. I’d call it determination,
inquiry and pity. He meowed again. Then he whapped me on the forehead with his
paw as if he was saying, “Don’t you get it? She was right. You hear the song,
but you don’t hear the words.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">As
if on cue, the song played again.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“<i style="mso-bidi-font-style: normal;">And God sent salvation…”<o:p></o:p></i></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Is
it really that simple? Why did she have to die for me to hear this message? <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Love crucified arose<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">And the grave became a place of hope<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">For the heart that sin and sorrow
broke is beating once again.”<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Wait,
that’s not Simon and Garfunkel. It’s one of her songs. I don’t have it on my
phone.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
looked at the clock. Four fifty nine.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
shut off the alarm. I picked up the scalpel. Instead of putting it back in the
nightstand, I opened it and broke off the blade, wrapped it in aluminum foil
and flushed it down the toilet. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
turned on the shower and stepped under the hot water.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">There
was a loud buzzing noise. It was the alarm. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">My
head popped up from the pillow as my arm reached out and pushed the switch to
stop the buzzing. My chest felt warm and clammy as I turned away from the alarm
and looked.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">There
was her long brown hair splayed out across the pillow. I watched as her chest
moved up and down with long even breaths. I kissed her hair and she turned
toward me and smiled. I kissed her cheek as she opened her eyes.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I
think you should get a chest X-Ray today,” I whispered. “Check out that cough
you’ve got. It’s probably nothing, but it’s better to be safe than sorry.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Or
suicidal, I thought.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Oh,
and what’s the name of your church?” I added. “I think I’ll try to meet you
there this weekend.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She
murmured something Presbyterian and went back to sleep.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
stopped and looked out the window and gazed into the gray sky. Then I Looked
down at her, peacefully asleep.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Thank
you,” I whispered.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
pulled off my scrub bottoms and stood under the warm spray of the shower,
washing the sweat, sorrow and guilt away.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<br />David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-9074934606037311172017-09-24T13:25:00.000-07:002017-09-24T13:25:07.918-07:00Protesting<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Times New Roman, serif;"><span style="font-size: 18.6667px;">Poor Luck University offers the following new major:</span></span></div>
<div class="MsoNormal">
<span style="font-family: Times New Roman, serif;"><span style="font-size: 18.6667px;"><br /></span></span></div>
<div class="MsoNormal">
<span style="font-family: Times New Roman, serif;"><span style="font-size: 18.6667px;">Protesting</span></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">A lucrative career can be had for the graduate
majoring in Protesting. The political climate of the 21<sup>st</sup> century
has creating a thriving job market for graduates with a BA in Protesting.
Salaries start at around $50,000 annually, but can balloon to over $100,000
during Presidential election years. Professional Protesters must be willing to
travel frequently and spend several hours a day outdoors. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Curriculum:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Signage 101 and 102:
Introductory courses which instruct the student in sign design, choosing
durable materials which will resist harsh weather, rotten fruit, tear gas and
conservative flatulence. These courses are required prerequisites for Placard
Messaging 300.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Hood and Mask Design 100: Another introductory level
course which explains the variety of masks and hoods available to the
professional protester. This course delves into the variety of materials
available, whether both nose and mouth holes are necessary and when to wear
such protection.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Chanting and Slogans 201: This intermediate level
course teaches the art of creating catchy and news worthy slogans. Emphasis is
placed on simplicity and directness of the message. This course is a
requirement for Placard Messaging 300.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">White Privilege 300: This upper level course studies
the reality of white privilege, particularly as it pertains to the male portion
of the population. The origins, violent nature, historical trends and methods
for its elimination will be studied in depth. Field study may include visits to
Monticello, Virginia; Vidor, Texas and Trump Tower.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">True Fascism 302: This upper level course examines the
danger that the fascist portion of society poses to the future of democracy.
This course usually is taken after “White Privilege 300.”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Placard Messaging 300 and 301: Upper level course
which studies the history of protesting signage, the psychology of slogans and
appealing to the ignorant masses.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The Deplorables: The True Enemy?: This senior seminar
examines our traditional society, delving into the origins, beliefs and the
ultimate destiny of this segment of the population.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Windows: This senior seminar presents the basic
construction of most windows and discusses the most effective way to smash them
to the greatest effect. Field work on the Berkeley Campus may be necessary.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Shouting and Chanting: This required senior seminar
allows the student to expand upon the groundwork established in Chanting and
Slogans 201. Coordination of verbal messaging and voice projection are part of
the discussion.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Suggested Reading:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Rules for Radicals: A Pragmatic Primer for Realistic
Radicals <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">by Saul Alinsky<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">What Happened by Hillary Clinton<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Dreams From My Father: A Story of Race and Inheritance
by Barack Obama<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">A People’s History of the United States by Howard Zinn<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<br />
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Interns: the Bad and the Beautiful by Bill Clinton <o:p></o:p></span></div>
David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-43927421388222334282017-09-04T14:12:00.000-07:002017-09-04T14:12:25.166-07:00Stages of A Relationship (Or How to Stay Married)<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> </span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Stage
One (Dating)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Woman:
“Dear, could you put the box in the car, please? Thank you.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Man:
Shrugs his shoulders and puts the box in the car.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Stage
Two (Honeymoon)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Woman:
“Forget the box.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Man:
Smiles and carries his bride inside.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Stage
Three (Newlywed)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Woman:
“Honey, could you please put the box in the car?” Whispers in his ear: “I’ll
make it worth your while.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Man:
Smiles, shrugs his shoulders and throws the box in the car.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Stage
Four (Fifth Anniversary)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Woman:
“Put the box in the car, please.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Man:
Starts to reply, stops himself, shrugs his shoulders and puts the box in the
car.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Stage
Five (Tenth Anniversary)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Woman:
“Put the box in the car.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Man:
Stands with his arms across his chest, stares at the box for five minutes,
shrugs his shoulders, then puts it in the car.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Stage
Six (Twentieth Anniversary)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Woman:
“Put the damn box in the car.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Man:
Picks up the box, muttering to himself, drops it three or four times, then
shrugs his shoulders and puts it in the car.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Stage
Seven (Thirtieth Anniversary)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Woman:
“Why isn’t this box in the car?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Man:
Shrugs his shoulders and puts the box in the car.<o:p></o:p></span></div>
<br />
<div class="MsoNormal">
<br /></div>
David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-59892600027303353202017-04-30T13:12:00.000-07:002017-04-30T13:12:09.329-07:00Thank You<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> Thank You<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">He
shook my had again.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I’m not sure I deserve this.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Not
deserve thanks after toiling for hours in the operating room? <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Bruce
was a complicated case. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
became involved on a Thursday afternoon.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“What’s
the problem,” I asked, a bit of trepidation in my voice.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She
told me the tale of Bruce’s hiatal hernia and transfer to our facility and then
came to the point.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Free air. A surgical emergency. At
least it’s two in the afternoon, rather than two am.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“What’s
Bruce’s overall condition?” I queried.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Septic
shock, BP 80/50, heart rate 130, O2 saturation 91%, about to be intubated,” she
answered.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“OK,
I’ll be there shortly.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
called the OR as I drove the short distance back to the hospital.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I didn’t have anything else to do
today, anyway.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Open
up his fluids,” I ordered. “We need to get him as good as we can to go to
surgery.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Sitting
at Bruce’s bedside was his father, very concerned and worried.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You’re
going to help my boy?” he asked softly.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“He
is going to be alright?” his father asked again, hope in his voice.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
OR crew arrived and he was wheeled down to surgery.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Thank
you,” Bruce’s father said as I turned to follow the stretcher down to surgery.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
looked back at him.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I
haven’t done anything yet,” I responded.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Yes,
you have done a great deal.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
didn’t answer, just turned and walked out of the ICU, following Bruce to the
OR.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I hope he still wants to thank me
after I’m done.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
was not too confident about Bruce’s chances.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Bruce
managed to survive the induction of anesthesia, maintaining his blood pressure,
although his oxygenation was borderline, hovering around 94%, even with 100%
oxygen.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“OK,
let’s go,” I exhorted the OR crew.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
made an upper midline incision and was in the belly in about a minute, greeted
by a flood of turbid, green fluid.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Suction
and some laps and a culture tube,” I requested, all neatly passed to me and my
assistant.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Not good, not good at all.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Looks like this is the problem. Why do
you have such a big liver?<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Easy, gently, don’t make things
worse.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“It
feels like there is a little gremlin up in the chest holding onto the stomach,”
I remarked to no one in particular.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Quite
a mess,” I commented out loud.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Looks like it’s been going on for two
or three days.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Looks like a mixture of antifreeze
and poop.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
area of necrosis started a couple of centimeters from the gastroesophageal
junction and extended along the greater curvature to the proximal antrum.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Looks like he’ll be getting a sleeve
gastrectomy. He certainly qualifies as overweight.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Sleeve
gastrectomy is the preferred operation <i>du
jour</i> for weight reduction.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">That should do the job.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Should be a save for modern medicine.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
went to talk to Bruce’s father. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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…”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Do
you have any questions?” I finished.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Thank
you, thank you for your efforts and taking the time to talk to me,” he replied
and we shook hands.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">He
sat down, waiting for a signal that he could go to see his son.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">‘Give
the nurses a few minutes to get Bruce all settled and then they should let you
come to see him,” I added.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Thank
you,” he said again.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
went back in to the ICU. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
checked on him later that evening and there was little change.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Ok,
sounds like everything is being done,” I commented.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Looks
like he’s turned the corner,” I told his father.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Thank
you,” was the reply.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Except,
it wasn’t all smooth sailing. Bruce complained of persistent nausea and
vomiting.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">X-rays
of his abdomen reported: “Retained Barium in the gastric fundus, mild ileus.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Something’s amiss. I took out his
fundus.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Looks
like a fold or ridge leading to the fundus,” Dr. S commented.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Except,
I took out that part of his stomach. I think that’s a large contained
perforation,” I observed.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Should
I biopsy it?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
met with Bruce and his father a few hours later and explained the situation.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Bruce
just nodded his head.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Thank
you for explaining it to us and for working so hard to take care of my son,”
Bruce’s father replied.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“It’s
my job,” I answered.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
wasn’t sure I deserved any thanks for what I viewed as a failure. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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…<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Thank
you,” his father said.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Your
welcome,” I replied. “I hope this is the last surgery Bruce needs.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Something
<b><i>was</i></b>
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<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe Interventional Radiology can
help.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
reviewed the scan with the radiologist and determined a new could be safely placed.
Bruce had the procedure the following day. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Two
hundred milliliters of slightly greenish fluid was drained and Bruce was
better,<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">But,
he still had a fistula.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I guess he needs more time.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
met with Bruce and his father and explained the situation. Bruce just nodded
his head, resigned to waiting.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Thank
you for taking the time to explain Bruce’s condition,” his father said.<i><o:p></o:p></i></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I don’t deserve thanks. I should be
apologizing.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Bruce
was home about four days when his father called.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Bruce
keeps vomiting and he had fever this morning,” he reported.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Bring
him back to the hospital,” I advised.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Thank
you for calling me back so quickly,” he replied.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“No
extravasation or fistula demonstrated on this exam” the X-Ray report stated.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
reviewed the images with the Radiologist.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Everything
went straight through and I don’t see anything outside the stomach,” Dr. H
stated, a touch of excitement in his voice.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Looks good to me.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Thank
you for being so patient with my son and for taking care of him,” Bruce’s
father remarked.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You’ll
be with him when he comes to the office?” I asked.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Yes,
I’ll be sure to get him there, Thank you again.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Your
welcome,” I replied.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Thank
you.” <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Thank
you.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Thank
you.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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:<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Thank
y’all.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
only bit of Texas I’ve adopted after more than twenty five years.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> <i><o:p></o:p></i></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<br />
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-4747760712639758352017-03-05T17:44:00.001-08:002017-03-05T17:44:58.169-08:00My Surgery<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-size: 14.0pt; line-height: 107%;"> </span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Probably just my GERD acting up.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
took my Prilosec and an antacid and went on my way. The pain, however, stayed
with me.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">All
day.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">And
the next day.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">And
the next.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">This is annoying. It must be more
than reflux. Maybe it’s my gallbladder?<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Sure,”
he answered.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Agreed,”
I answered as I went on my way, still with pain, but at least with the
knowledge of what was causing the problem.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Pain
came back, but different than before. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It’s just my reflux. I’ll go back on
my Prilosec.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
pain was a little sharper than previous, but only lasted about twenty minutes,
at first.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Definitely atypical for gallbladder.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Still,
it was just an annoyance. And, I did have gallstones.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">RUQ abdominal pain, lasting for
hours, radiating to the back? No question. This is my gallbladder.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Pain,
however, can wear you down. Particularly when it occurs every day and lasts for
hours. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">A
daily cycle began. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Every
day.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">You need to be a good patient.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I guess there’s no way I can operate
on myself? I’ll just have to trust my partner.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe I don’t really need this
surgery.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">But,
the day before surgery the real pain returned.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I guess it’s time. <o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">My
wife and I parked the car at six twenty five and went into Bayshore Hospital’s
Day Surgery.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“This
way Dr. Gelber, we’ve got the VIP suite ready,” one of the nurses chimed.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Room
fifteen?” I answered. “Nothing very VIP about it.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
donned my hospital gown and my red, no skid socks and lay down on the stretcher
to wait.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
wasn’t very long.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">There
was another short wait until the anesthesiologist made an appearance. Unlike
some other VIP’s I did not choose any particular anesthesiologist. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">They all strike me as having
equivalent levels of skill and I trust my patients with all of them.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Finally time to start.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Dr.
M made another appearance. He plugged an infusion of morphine into my IV,
watched as the steady drip…drip…drip began and left. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">A little, certainly not excruciating.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Some,”
I answered.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">A
half milligram of Dilaudid was pushed through the IV. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
worked.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">As
a matter of fact the accumulated Morphine and Dilaudid worked <b><i>very </i></b>well.
<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
couldn’t stand up, couldn’t pee, couldn’t do much of anything for about four hours. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">No doubt he’s concerned about me,
rather he’s concerned that if anything happens to me he won’t get fed.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
looked at the photos from the surgery. The gallbladder didn’t look inflamed, my
liver looked normal.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You
had a lot of little stones,” Dr. L. reported.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Makes sense, goes along with the pain
I was having. Probably passed a little stone every day.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
does, however, lead to happy patients and good care.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<br />
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-32222724599666811422017-01-29T13:56:00.001-08:002017-01-29T13:56:36.898-08:00Super Bowl Prediction 2017<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Super
Bowl LI.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Super
Bowl LI: New England Patriots vs Atlanta Falcons.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">But,
such an important event deserves far closer scrutiny and analysis. I will start
with the Patriots.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">What
are Patriots, particularly those from New England?<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Is
this a fair matchup?<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Surely,
dear reader, you have heard of Alfred Hitchcock’s “The Birds.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Falcons
27 Patriots 17<o:p></o:p></span></div>
David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-4990825351210801632016-12-03T10:57:00.000-08:002016-12-03T10:57:01.456-08:00Memo<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> Memo to the Medical
Staff<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">From
the CEO,<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">A
discussion at the recent meeting of the Hospital Employee Safety and Serenity
(HESS) Committee brought to light work conditions which have caused some of our
employees to experience feelings of uneasiness and agitation in the hospital
work environment.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Specifically,
the term “Physician’s Orders” inherently creates an intimidating work atmosphere.
The idea that one individual may <b><i>order</i></b> another individual to perform
any task, even a necessary one, strikes the HESS Committee as potentially threatening
and harkens back to days of master and slave; of one individual lording over
another for personal gain, thus introducing charges of racism, misogyny and xenophobia
into our workplace. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Several
members of the nursing staff have expressed feelings of fear, anxiety and apprehension
when having to carry out “orders.” <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">To
remedy this situation and fend off possible litigation, the term “Physician’s
Orders” will be modified to reflect these more enlightened and progressive
times.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Several
alternative phrases were proposed, including Physician’s Directions, Physician’s
Mandates, Physician’s Instructions, Physician’s Advice, Physician’s Commands
(immediately rejected) and Physician’s Guidelines. After much discussion and
debate, however, the HESS Committee has reached a consensus. The new
terminology will be “Physician’s Suggestions.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
Committee feels, very strongly, that this phraseology will promote the greatest
sense of collegiality, warmth and acceptance in the hospital workplace. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
hope this change will not cause any undue stress and the that the medical staff
will agree to this adjustment and see things in the proper light of twenty
first century reality.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Thank
you<o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-12806325717363539822016-10-29T12:04:00.000-07:002016-10-29T12:04:06.924-07:00Walking Miss Daisy<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">About
four years ago Miss Daisy wandered or was abandoned into our life. It was a
typical Sunday. I was at the hospital making patient rounds when a call from my
wife.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I
found two dogs in the circle,” she reported. “I’m texting you their picture.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“OK,”
I answered, “I’m still making rounds, but should be done home in an about an
hour.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I
think someone dropped them off in the neighborhood,” she concluded. “One is a
Basset Hound.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
picture arrived. There was a rather frazzled looking tan and white lady, fairly
tall and thin. And there was her companion, a mostly black, fine looking Basset
Hound. The phone rang again.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I
put the dogs in the driveway and gave them some food,” Laura reported. “Of course,
no collars or tags.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Maybe
they’re microchipped?” I wondered, full well knowing that the odds finding their
true owners was around a thousand to one.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Needless
to say, the owners remained a mystery and Freckles, a Weimariner mix, and
Daisy, the Basset Hound were adopted into our family, joining our other four
dogs.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Daisy,
or Daisy Mae, as I call her, paying homage to Lil’ Abner, had glaucoma and was
already blind in her left eye. Freckles had very early heartworms which were
successfully eradicated with antibiotics.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Daisy
Mae started on a regimen of eye drops, the blue bottle twice a day, the beige
one three times and the pink and green ones once at night.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">But,
this article isn’t about the life story of Daisy Mae and Freckles. No, it’s
about walking poor Daisy. I wonder if poor is the proper term? Daisy Mae has
since gone on to lose the vision in the right eye which required surgical
enucleation, that is, it was removed. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Now
she is Daisy Mae, the blind Basset hound.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Poor
Daisy,” one might say. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">But
is she poor?<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">If
you are familiar with the Basset Hound, <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">(see
“Man’s Best Friend, The Noble Basset Hound <a href="http://heardintheor.blogspot.com/2010_04_01_archive.html">http://heardintheor.blogspot.com/2010_04_01_archive.html</a>)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">then
you know that this breed of dog lives its life on its own terms. They are not
mean or unruly, just independent and stubborn. Their keen sense of smell is
second only to the Bloodhound among dogs, following their nose to the finest
discarded garbage in the neighborhood. They instinctively find the most
comfortable spot in the house to sleep, happily usurping your favorite
overstuffed chair. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Should
you feel the urge to relax in this chair they will give you a look of shock
that you would even consider taking <b><i>their</i></b> spot. That is if you are able
to wake them.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Now
consider Miss Daisy Mae. All she has is her amazing nose. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
chore, or is it joy, of walking her often falls on me. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Call
her name and she rises from her bed, sensing that it is either time for treats
or a walk. She trots through the kitchen, deftly avoiding cabinets, garbage
cans, chairs and other dogs, barking in her deep, loud Basset voice until she
is hooked to the leash and heads to the door. Sometimes in her excitement she
bumps into a couch or table leg, but she manages, always leading <b><i>me</i></b>
to the door. Somehow her nose can smell the step off the front stoop as she
jumps down and is on her way.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">First
order of business is emptying her bladder. With nose millimeters from the
ground and ears flapping she finds the perfect spot, squats and nature’s call
is answered. Now she is free to follow her nose. Literally.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">And
what a nose. Sniffing subtle aromas may be almost as good as, or even better,
than sights. Daisy Mae walks along, gingerly sniffing, always along the edge of
the sidewalk close to the grass. Her nose can “see” where the sidewalk ends as
she only veers off to pursue a new and, I assume, wonderful, interesting,
enticing scent. Once an odor is discovered she will stop and sniff and snuffle until
she’s had her fill of whatever she has unearthed. Then, she will raise her
head, give a snort, cleansing her nostrils of the scent and go on her way.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Methodical,
slow and steady, and relentless she goes her way, oblivious to me, her leash
and any other impediments. And, if her chosen path varies from mine we are left
with a classic battle of wills. Me, pulling the leash, against Daisy’s 65 low
slung, dense pounds.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“There’s
an interesting scent this way,” her face says. “I’m not budging until I
investigate.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Most
of the time she wins.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Then
there are those moments of joy, for Daisy, at least. She will come across a
trail that excites her. A howl escapes from her throat, followed by three loud
barks and another howl. She forgets her blindness, she forgets me, she forgets
everything but this unseen, odiferous trail. Off she goes at a fast trot, nose
to the ground, determined and resolute as she tracks down a particularly
pungent, perhaps dangerous and nefarious quarry. The chase lasts for thirty or
even sixty seconds until she stops and raises her head pretending to look into
the distance before she turns back to me and we begin the trek home.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">But,
in that moment she could “see.”<o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-36915763448866877462016-08-07T13:20:00.000-07:002016-08-07T13:20:16.304-07:00The Joy of Surgery<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
was a bit exhilarating. By all accounts it should have been a mundane simple
case. Tom was the patient. He had suffered with tuberculosis thirty years ago,
but was pronounced cured after his treatment. Now he had a new problem, or was
it a new manifestation of his old Tb?<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">He
came to me with a mass in his neck, not really painful or tender, but draining
through the skin for about a month. He was a smoker and drank a bit, but
otherwise was healthy. His passion was fixing cars, a job which he began every
morning at about 4:30.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
mass was a nuisance to him and his coworkers. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Can
you do it soon? Maybe tomorrow?” Tom asked.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">He
came with the report of a CT Scan of the neck which revealed the large mass
with a low density center. Pulmonary doctor was hoping it was tuberculosis and
not cancer.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
mass was three centimeters. It was inferior to the angle of the jaw, which
suggested it was not from the parotid gland, and there was a sinus tract
opening draining some cloudy, particulate fluid. There was no erythema and it
was not tender.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">What’s best? This looks more like
cancer than Tb, a large node with necrotic tumor. Maybe a needle biopsy first? Still,
it has ruptured through the skin which makes it unlikely to heal. It needs to
be removed. Maybe I can do it this week. The schedule isn’t terribly busy.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“OK,
Tom. Surgery in two days,” I answered. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
went on to explain the procedure in detail, did the necessary paperwork and
sent him on his way.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
night before Tom’s operation I considered what his surgery might entail as I
perused my schedule for the following day. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Inguinal hernia, venous access port,
gallbladder, another inguinal hernia and Tom.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Everything straightforward and
uncomplicated. What about Tom? Just a neck mass. But what if it’s more than
that? Just do what you have to do.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
went to sleep.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
next morning I breezed through Mike’s inguinal hernia, Mary’s VAP, Lupe’s
gallbladder and Oscar’s hernia.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Tom
smiled at me as I greeted him in the pre-op area.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Do
a good job, doc. I’ve got a souped up Mustang waiting for me,” he conveyed.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Don’t
worry. We’ll take good care of you,” I gave my standard answer, the perfect
words for a patient awaiting an operation, understated enough to provide a sense
of calm and confidence, to the point, yet clearly stating that we <b><i>will</i></b>
take care of everything.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Tom
went to sleep and the dressing on his neck was removed, revealing the mass
which was bulging against the skin. He was prepped and draped and the surgery
began.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
started with an elliptical excision intended to remove the skin overlying the
mass with the draining sinus. Skin flaps were raised lifting the skin and
platysma off the underlying mass and the tissue surrounding it.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Find the sternomastoid muscle.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">This
muscle, the sternocleidomastoid is always a safe landmark when working around
the neck. Important structures like the jugular vein and carotid artery run
beneath it, other structures, like the parotid gland usually come down to it,
but are easily separated. So the first task was accomplished quickly. The
anterior border of this muscle a couple of centimeters away from the mass was
exposed. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">All
the tissue superficial to this muscle was dissected away, the plan being to
remove this normal tissue with the mass to ensure complete removal if it turned
out to be cancer.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">But
things began to get complicated.<i><o:p></o:p></i></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">This mass is growing into the muscle.
Where’s the jugular vein?<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
identified this vein, once again, inferior to the point where the mass began, I
began dissecting along the vein, isolating and ligating some side branches.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Uh-oh. This is not going to be
simple.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
mass was abutting the vein.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It’s probably stuck.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Indeed,
it was. As I pushed and teased the fat away from the vein, all of a sudden I
was inundated with dark blood.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“5-0
Prolene, por favor,” I asked.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">There
was a hole in the jugular vein, but it wasn’t bleeding as much as I would
expect. The blood was only coming from the thoracic side of the vein, none from
the intracranial portion.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The tumor must be growing into and
occluding the vein above where I’m working.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
hole was quickly repaired.<i><o:p></o:p></i></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Time to reassess the situation.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
was clear that this was going to be a malignant process, but at this point I
sent a piece of the mass to the pathologist to be sure.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Squamous
Cell Carcinoma,” she reported.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">No surprise..<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
mass was sitting squarely between the sternomastoid muscle and the jugular
vein. It was now clear that it was going to take a neck dissection of some sort
to remove it. The muscle and the vein would have to go.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
went to work above the mass.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“What’s
that structure?” I pimped my assistant.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Uh…”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“It’s
the tendon of the digastric muscle. And this nerve?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Duh…”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“The
hypoglossal. And that artery is the carotid.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
don’t get to see these structures very often, although they are landmarks a
surgeon always looks for in the course of any neck dissection. The digastric
muscle is another safe place to dissect. I also spied the inferior edge of the
parotid gland, the jugular vein above the tumor and the spinal accessory nerve
and trapezius muscle soon came into view.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
was time to commit. I dissected and encircled the jugular vein inferior to the
mass, ligated and divided it. I divided the sternocleidomastoid muscle with
cautery. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">These
two structures were dissected off the underlying tissue together, once again
removing the fatty lymphatic tissue with the specimen. The carotid artery and
vagus nerve were preserve as they were not involved with the tumor. I reached
the digastric muscle and dissected from the central tendon posteriorly, lifting
the jugular vein off the muscle, followed by the sternomastoid muscle and the
tumor.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">A
branch of the spinal accessory nerve, the one going into the sternocleidomastoid
was divided while the main trunk of this nerve was preserved. Finally I was
left with muscle and vein above the tumor. The vein was transected and sutured
closed and the muscle was divided and the specimen was free, passed into the
hands of the tech.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
took a moment to admire my handiwork. It looked like a page from Netter.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">There
were two ligated ends of the jugular vein. The carotid artery from the inferior
neck to above the bifurcation was clearly seen as was the hypoglassal nerve
crossing it. The vagus nerve ran alongside the carotid, perfectly intact. The
lower end of the parotid gland stood out as did the digastric muscle. The most
anterior portion of the trapezius muscle was also clearly exposed with its
spinal accessory nerve. All in all it was a very neat and clean modified neck
dissection.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">A surgical Rembrandt? Or Picasso? <o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Tom’s
case was a demonstration in how surgery can be so appealing to the inquisitive
young mind. Tom’s was not a perfect operation and he was almost certainly not
cured, but this operation demonstrated
the joy of surgery.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Joy
of Cooking? Of course. Joy of Sex? Certainly.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">But,
the Joy of Surgery?<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">What
is this joy that can come from cooking? Or sex? Or surgery? What is joy? <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
is defined as the emotion evoked by well-being, success, or good fortune or by
the prospect of possessing what one desires. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Such
joy is the certainty that if you follow all the proper steps, do things in a
certain way you will be rewarded with a contented or blissful or exhilarating
outcome. It could be a delightful meal, or a wonderful sexual encounter, or a
surgery which has a perfectly successful outcome for the patient and surgeon.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">This
does not mean that one needs to smoke a cigarette after the operation. But, an
operation which provides complete relief for a sick patient while providing a gratifying
challenge, sans frustration, worry or doubt would be considered joyful. Tom’s
was such a case.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
think the closest thing would be collecting the fruits of a large wager on a
perfectly handicapped horse race combined with the feeling one gets when
looking at a beautiful painting.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Dissecting
out all those named structures, knowing that it’s safe to cut along this
muscle, that an important nerve is lurking nearby or that the jugular vein may
be removed or that the external carotid may be ligated, but not the internal,
or that this gland is the parotid, but if the dissection is more anterior then
the submaxillary (or is it submandibular?) gland will be encountered are some
of the important little facts surgeons must learn if any time is spent lurking
around the neck. Every operation is filled with such little facts. Be aware of
the common bile duct, or recurrent laryngeal nerve, or ureter or this artery or
that.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">All
those little things start with basic anatomy, initially taught in the first
year of medical school. But, beyond Anatomy 101, and far more important, are the
knowledge and wisdom to properly assess a situation and make the appropriate
decisions. What operation to do, when to do it, when to alter the plan to accommodate
unforeseen pathology are skills which are difficult to teach. Book knowledge
certainly helps, but there is no substitute for gray hair.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
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<br /></div>
David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-77294146358869761532016-05-28T11:06:00.003-07:002016-05-28T11:06:38.970-07:00Day of the Gallbladders<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
looked like it was going to be a good day. I wasn’t on call, I would be off the
weekend and all I had scheduled for the day was four elective cases, all
laparoscopic cholecystectomies. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">How could the day be any better?<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
surgeon’s prayer popped into my head:<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Lord,
please protect me from the interesting cases and don’t let me screw up today.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Cholecystectomy
is the most common operation that is performed in the United States.
Gallbladder disease occurs as a consequence of diet, hormonal changes, genetics
and physiologic changes involving the rest of the body. It seems that
everything affects the gallbladder. Gaining weight, losing weight, pregnancy,
illness, stress and probably a whole bunch of other things cause the
gallbladder to form stones, stop functioning or become inflamed. Whenever the
gallbladder starts to behave badly one can rest assured that a friendly general
surgeon is nearby to address the problem.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
was six thirty in the morning, the dogs were fed and I was scheduled to start
in an hour.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe I can get rounds done before I
surgery.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
was a rare day. I only had patients at one hospital, the same venue where the
cases were scheduled. I arrived at six fifty five and greeted my first patient
in Day surgery.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maria
was forty, about five foot one and weighed in at two hundred sixty pounds. She
had multiple gallstones and had suffered through repeated episodes of right
upper quadrant abdominal pain. She had gone to the ER once, but otherwise had
endured multiple nights of suffering.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I
just get up and walk around or sit in the chair until the pain goes away,
usually after a couple of hours. I take some Motrin, which helps a little.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Textbook case. All Four F’s: Female,
Fertile, Forty and ‘Rotund’.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
went to the hospital computer and checked on each of my in house patients,
their vital signs, lab results and such. I only had five patients to see.
Everyone looked good in the computer.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I guess I need to see each one in
person. <o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
ran up to the third floor, the post surgical unit. I saw Bill and Irma and
Lucille, each post op from laparotomies and each was doing well. Notes and
orders were written (the good old days, before computerized everything) and
then I ran down to the OR to start Maria’s surgery.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She
was just going to sleep when I walked into OR five. I went out to wash my hands
while she was being prepped. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Draperies
please,” I asked.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
tech handed me a towel and I began to drape Maria.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">All
the proper tools were passed off and connected and surgery commenced. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
infiltrated some long acting local anesthetic in Maria’s belly button area,
made a small incision, elevated her abdominal wall and tried to pass the Veress
needle. This needle is what I commonly use to insufflate the abdomen, that is
blow it up with carbon dioxide gas. Only the needle wouldn’t pass. I put it in
up the hilt, but no go.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She doesn’t look to be that large.
But, women tend to have their adipose tissue in the abdominal wall, I guess
Maria has a bit more than I thought.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I
need a longer Veress needle.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">In
about a minute the circulator returned with the 150 cm needle which I was able
to pass into the abdomen without difficulty.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I hope that’s the only glitch for the
day.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">And
Maria’s case went off without a hitch. Inside her abdomen there wasn’t much
fat. Each structure stood out. The gallbladder was hanging off the liver, the
common bile duct was easily seen, and the cystic artery nearly jumped out at
me. It was spread, spread, clip, clip, clip, cut, clip, clip, clip, clip, cut,
then snip, snip, snip, snoop and in five minutes the gallbladder was in a
pouch, pulled out through the epigastric wound and on the back table. Ten minutes
later the final band aids were laid over the last of Maria’s wounds as she
began to wake up. Thirty five minutes after she had gone to sleep she was in
the Recovery Room.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I should have time to see my other
two hospital patients.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
saw Joe and Juana on the fourth floor. Neither had a problem which would
require surgery. I stopped to say “hello, how are you, you should be going home
soon and then went back to the OR to operate on Michael.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Michael
had been having pain for years, always in the upper abdomen, radiating to his
back, occurring almost every day. He had gone through endoscopies, CT Scans,
MRI’s, ultrasounds and more endoscopies. Finally, he found a GI specialist who
ordered a HIDA Scan. This is an anatomic and functional test of the
gallbladder. In Michael’s case the HIDA revealed his gallbladder only emptied
4% when stimulated and, maybe more important, his symptoms were reproduced,
exactly. I told his there was an 85-90% chance his pain would be relieved by
surgery.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">He
was being wheeled into the OR as I finished my rounds.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Should be straightforward. No stones,
chronic symptoms, overall in excellent health.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Never
make such assumptions.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Michael’s
surgery started off simple enough. The gallbladder was partially intrahepatic,
but that just means a little more dissection until the gallbladder is free. I
began in the usual way, incising the thin layer of peritoneum over the neck of
the gallbladder and dissecting this peritoneum and the some surrounding fat
away from the wall of the gallbladder. I lmost always start on the inferio
lateral aspect of the gallbladder, where I should be safely away from the
common bile duct.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">As
I began Michael’s dissection I saw a bluish structure just below the cystic
duct and going towards the liver.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Not the right spot for the common
bile duct or any bile duct. Be careful. Maybe it will be easier on the other
side of the gallbladder.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
began dissecting on the medial aspect of the gallbladder. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It looks like there is another duct
on this side. Maybe the gallbladder is lying between the right and left hepatic
ducts? The structure in the middle looks like the cystic duct. <o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
started working higher on the gallbladder, away from any ducts, I hoped.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">This is becoming far too much work.
This was supposed to be my easy case.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">As
I dissected along the medial wall of the gallbladder I was able to identify a
duct running along this part of the gallbladder and then going towards the
liver. Luckily, I was able to separate this duct from the gallbladder.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">That must be the left hepatic duct.
At least Michael is not too chunky.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
retracted the gallbladder to the right and began teasing out the cystic duct.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Better check that duct like structure
on the right side of the gallbladder.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It’s
a good thing I did, because what I thought was all cystic duct turned out to be
what I now presumed to be the right hepatic duct almost fused to the back wall
of the gallbladder. I tried to separate these two structures. No luck. I did
manage to find what I presumed was the cystic artery, very short and running
along the medial aspect of the gallbladder, almost tethering the gallbladder
between the two hepatic ducts.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe take it from the top down, like
the old days.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">And
so I began working on the fundus of the gallbladder. I pushed the liver up and
retracted the gallbladder down and was able to separate the gallbladder until
it was attached buy only the cystic duct, which was still fused to the right
hepatic duct.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I’ll just take where it’s safe and
leave the rest behind. <o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
used a stapling device to divide the gallbladder at its neck, being careful not
to injure the bile ducts.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Finally it’s done. This was far too
much work.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Michael
woke up without a hitch, oblivious to the torture I had suffered. His operation
which normally would have taken about thirty minutes had lasted over two hours.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Next
was Michelle, twenty one, with pain for a week and a big stone impacted in the
neck of the gallbladder. Michelle was typical of most patients with
cholecystitis. That is she had persistent episodes of pain, and stones which
either intermittently passed from the gallbladder through the bile duct,
causing “biliary colic” or had big stones which would cause obstruction of the
gallbladder with either acute symptoms of severe pain and tenderness, “acute
cholecystitis” or paroxysmal pain, “chronic cholecystitis.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Michael and Michelle, good name for a
duo. And now we present “Michelle and Michael” the gallbladder singers.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">My
first glance at Michelle’s gallbladder revealed only that is was very
distended. It wasn’t very inflamed and there was only a brief moment when it
seemed like there might be some difficulty grasping it. There was a big stone
filling the gallbladder neck, but I was able to retract the gallbladder to the
right so that I could dissect the cystic artery and duct. Fifteen minutes later
the gallbladder was in the endopouch.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Homefree.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">But,
it wouldn’t come out. The pouch was half in and half out of the abdomen,
pulling it out through on of the larger trocar sites. I grabbed the gallbladder
and tried to deliver it out of the pouch and abdomen. I was rewarded with a
tiny piece of the gallbladder wall. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Keep at it. You always win in the
end.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
tried to grab the stone with the ring Forceps, a clamp which has two rings
which is ideally suited to grasping gallstones and pulling them out of the
Endopouch. Michelle’s stone was big, really big. With one lucky swoop I managed
to get the jaws of this clamp around the stone. I pulled it up towards the
small opening in the abdominal wall. It was equivalent to trying to put a camel
through the eye of a needle. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe I can break the stone up.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
tried to close the jaws of the clamp and break the stone into pieces. There was
a “snap” and then I was able to pull the clamp out, minus one of its jaws.<i><o:p></o:p></i></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">That is one tough stone.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
tried a different type of clamp. No luck. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">After
twenty minutes of pulling, prying and hoping I did what I needed to do.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Knife
please.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
made the incision bigger, big enough to deliver this baby. I made it bigger and
bigger until it was a mini laparotomy. Finally, I pulled pouch gallbladder and
stone out of Michelle’s abdomen. T<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
stone was five and a half centimeters in diameter, the size of a chicken egg. I
took a break for a minute, shaking my hand to relieve a cramp and stretching my
fingers after this ordeal. I closed Michelle in short order and got ready for
Owen.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I’m not sure they pay me enough.
Maybe Owen will treat me better. <o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
shouldn’t think such thoughts, surely I jinxed myself. Owen. Even now the name
makes me shudder.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Owen
was 78 years old and had typical complaints of RUQ abdominal pain. He had been
having pain almost daily for 6 weeks. His ultrasound revealed, and I quote,
“Multiple mobile stones,” and the gallbladder was not visualized on HIDA scan,
which suggests cystic duct obstruction and certainly explained Owen’s frequent
symptoms.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Are
you ready to get this over with?” I asked.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Sure
thing, Doc. I’m planning to play eighteen holes tomorrow,” He answered.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Well,
you may want to wait until the weekend,” I countered.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Owen’s
case started well enough. Pneumoperitoneum established without difficulty, all
the trocars placed and then I looked in with the scope.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">No
gallbladder. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">All
I saw was a bit of omentum stuck to the spot where the gallbladder was supposed
to be.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It must be underneath those
adhesions.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
teased the omentum away and was rewarded with a structure which looked like it
was the gallbladder. It was small to say the least, but it was where the
gallbladder was supposed to sit and I was sure I could see the common bile
duct.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Once
the adhesions were gone I began to retract the gallbladder superiorly as is
almost always done during laparoscopic gallbladder surgery. The gallbladder was
not only shrunken it was very hard to grasp. Every time I tried to grab it, it
would slip away. Finally, all I could do was push the liver superiorly. As I
tried to dissect this diminutive little beast it tore. I did see some stones
inside but I realized I was fighting a losing battle.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Scalpel,
please and get all the instruments to open,” I requested.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Better to have a big incision and a
healthy, whole patient, than four small incisions and a piece of the common
bile duct in the specimen jar.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Over
the years I have never had a patient complain that they had to have open
surgery. However, they definitely are not happy if they require multiple
surgeries to fix a complication.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">For
the next hour and a half I wrestled with Owen’s little nubbin of a gallbladder.
I managed to separate it from the liver and I thought I found his cystic duct
and junction with the common bile duct. The cystic duct was very short. I
stitched it closed, being careful not to narrow his CBD and I left a drain in
place.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
delivered a gallbladder which was the size of a nickel and contained a couple
of stones which filled its tiny lumen.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Two hours of work for that little
thing?<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Owen
woke up without a hitch.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“No
golf for a few weeks,” I informed him.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“There
goes my handicap,” he answered.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">At least I’m done.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">My
phone went off.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Consult,
ICU 21. Tad Schultz, acute cholecystitis.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I thought I was done.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
was now 3:30 in the afternoon. My plan to be done and home by one was just a
fading memory.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I guess I need to go check out Tad. I
wonder why he’s in ICU if it’s just his gallbladder which is the problem?<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Tad
was not in the ICU just because of his gallbladder. He had undergone coronary
artery bypass surgery thirty six hours ago. Now he was complaining of severe
upper abdominal pain, nausea and vomiting, all of which had commenced twelve
hours earlier.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Hello,
Mr. Schultz. I’m Dr. Gelber, one of the General surgeons here. They tell me you
have pain in your abdomen?” I inquired.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">He
was sitting still in his bed, an oxygen cannula draped across his face which
was flushed. The monitor to the right of his bed gave a clue to his condition. Heart
rate was 112, blood pressure 100/50, Respirations 22, oxygen saturation was
100%.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Looks like something is going on; something
more than just post op discomfort.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“It
hurts right here,” he replied as he pointed to the right upper quadrant of his
abdomen, right where his gallbladder sat. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“It
hurts to move, to breath, even to smile,” he added.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I wonder if it’s more than just his
gallbladder?<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Any
nausea or vomiting?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“All
night.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Had
a pain like this before?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Never.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
palpated his abdomen. He winced when I lightly tapped beneath the right costal
margin (below the ribs).<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It feels like there’s a mass there.”<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’ll
be back in a few minutes,” I said and I went to check the results of any
testing which had been done.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
sat a the computer, waiting for Tad’s data to appear.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I don’t feel like ding another
surgery today, especially on someone fresh from open heart surgery.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
tests revealed that his white Blood Cell count was 23,000, H/H 10.5 and 32.
Total bilirubin was 2.0, ALT 125, AST 114 and Alkaline Phosphatase 201. His
other labs were more or less normal. Ultrasound revealed a very distended
gallbladder with stones and a thickened wall at 10 mm.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">No question, Tad is sick and the
culprit is his gallbladder. Surgery would best be avoided if possible. Maybe Dr.
L can help.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Dr.
L was our local, friendly Interventional Radiologist.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Percutaneous
cholecystostomy, if you have the time,” I requested from Dr. L. “Mr. Schultz,
ICU 21. I think it would be best if he does not have to have surgery again so
soon.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Dr.
L agreed and two hours later Tad was sitting up, smiling with a tube running
from his right flank to a bag which was filled with golden brown bile.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
was not definitive treatment, but the drainage procedure bought time, allowing
Tad to recover from his open heart surgery without further complication. Six
weeks later he had a second surgery, an uncomplicated laparoscopic
cholecystectomy.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
day ended at around 6:00 pm. I had performed four cholecystectomies, tackling
gallbladders of a variety of shapes and complexities. My hand was still a little
sore from battling Michelle’s ostrich egg of a gallstone, but otherwise it had
been a successful day. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Cholecystectomy
can be one of the easiest surgeries to perform or extremely difficult. An
elective gallbladder surgery in a thin patient with little inflammation and
normal anatomy may take all of ten minutes. Meanwhile, at the other end of the
spectrum, a case like Owen, a small contracted, fibrotic gallbladder with anatomy
which is unclear will cause the best surgeon to pause and rue the day he chose
to work with a scalpel, rather than sit a dark room all day and read chest
X-Rays.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
thought about the surgeon’s prayer.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Lord,
please protect me from the interesting cases and don’t let me screw up today.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe
it needs an addendum:<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“And
please make all the gallbladder surgeries easy.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<br />
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-92231582206882033622016-03-26T08:42:00.000-07:002016-03-26T08:42:06.043-07:00Legacies<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">We read a great deal these days about President Obama’s
legacy, about he is trying to create a list of accomplishments which historians
will cite as the highlights of his eight years in office.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">But, when we think about our former leaders what pops
into our head are the quotes which we associate with each man. Reflecting on
this idea I present a list of famous quotes which are attributed to some of our
past Presidents. President Obama presents a stark contrast to the others, which
provides commentary on his memorable accomplishments.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“My fellow Americans, ask not what your country can do
for you, ask what you can do for your country.” John F. Kennedy<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“The only thing we have to fear is fear itself.”
Franklin D. Roosevelt<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Four score and seven years ago our fathers brought
forth, upon this continent, a new nation, conceived in Liberty, and dedicated
to the proposition that all men are created equal.” Abraham Lincoln<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“With Malice toward none, with charity for all, with
firmness in the right, as God gives us to see the right, let us strive on to
finish the work we are in, to bind up the nation's wounds.” Abraham Lincoln<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I feel your pain.” Bill Clinton<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Mr. Gorbachev, tear down this wall!” Ronald Reagan<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“States like (Iraq, Iran, & North Korea), and
their terrorist allies, constitute an axis of evil, arming to threaten the
peace of the world.” George W. Bush<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Until justice is blind to color, until education is
unaware of race, until opportunity is unconcerned with the color of men's
skins, emancipation will be a proclamation but not a fact.” Lyndon Johnson<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“If you've got a business—you didn't build that.
Somebody else made that happen.” Barack Obama<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">"If you like your health care plan, you can keep
it.” Barack Obama<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I did not include the famous “lead from behind” quote
because I cannot find documentation that President Obama actually said this. I
also must admit that thre is nothing scholarly about these quotes. Each is a
quote that popped into my head when I considered what was memorable about these
past presidents.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Just a little food for thought.</span></div>
David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-52801381015020424542016-03-14T17:17:00.001-07:002016-03-14T17:17:19.385-07:00A Horse is a Horse of Course...<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Jeremy
was a cowboy in the rodeo. He also was responsible for keeping me up for most
of three nights in a row. He was the fortunate survivor of a run in with a very
angry horse.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Animals
are supposed to be our friends, at least dogs and cats, horses, pigs and cows. Some
birds, the occasional snake and even tarantulas have been companions to
humanity. Our encounters with these domesticated beasts are supposed to bring
pleasure, happiness and feelings of wellbeing. Except, when they don’t. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Melvin
was set upon unmercifully by two feral dogs, losing large chunks of skin and
muscle from each leg and one arm before the beasts could be restrained. Sandy
was a young lady tattooed from head to toe. She had a pet python who mistook
her for his dinner one day and tried to swallow her whole. I see half a dozen
patients every year with fever and painful swollen lymph nodes secondary to cat
scratch disease. Bird bites, tarantula bites, dog bites and so many other bites
have made it into the hospital over the years.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">But
Jeremy; he stands out. Maybe it’s because he showed up in the ER very early in
my career in private practice; maybe it was the running battle between his
divorced parents, maybe it was the conversation with Dr. Red Duke, or the lack
of sleep I accumulated over the four days it took to stabilize him. Probably
all of the above combined to make him one of my more memorable disasters.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
had been out in private practice for about four months and I still had the
feeling of invincibility common to surgeons as they leave the safety of
residency and head out to save the real world. It was eleven pm when the phone rang.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Dr.
G this is Dr. F in the ER. I’ve got an eighteen year old man here who got
kicked in the right side by a horse. His heart rate is 130 and BP is 90. There’s
a big area of swelling on his right side. He’s on his way to CT as we speak.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“OK,
thanks, I’ll be in to see him,” I answered. I turned to my wife.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I
need to go to work,” I said.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Surgery?”
she asked.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Don’t
know. I hope it’s nothing major.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
pulled on some clean scrubs and left.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Jeremy
was just finishing his CT as I arrived. As he was wheeled back to the ER I
scrolled through his scan.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Broken rib, looks like a pretty big subcapsular
hematoma of the liver, not much else.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">This
was my reading of the scan, but usually I was pretty accurate, as I had spent
the last two years of my residency reading abdominal CT’s with the senior
Radiology residents.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
Radiologist’s official reading was in agreement. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Jeremy
was awake and alert, complaining of pain in his right side. He had been
competing in a local rodeo and one of the horses decided nobody was going to
ride him and decided to vent his anger on Jeremy, delivering a solid kick squarely to Jeremy’s
right side. There was a big bruise on his right side and I was sure I could
make out the imprint of a horseshoe. Certainly not lucky for Jeremy.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Jeremy’s
Dad was at his bedside showing nothing but the proper concern. Mom and
fireworks would come later.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Jeremy
stabilized after a couple of liters of IV fluids and I decided surgery was not
needed at this time. I tucked him away in the ICU and was back in bed by 2:00
am.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Later
in the morning Jeremy was looking fairly stable. Heart rate was around 110,
blood pressure was 110/70, urine output and oxygen saturation were good. His
hgb had dropped for 14 to 10.5.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Looks
like he’s pretty stable,” I reassured his dad.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“His
mother will be happy,” he replied.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I
haven’t met his mother yet,” I answered.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“She’s
been away, on a business trip. She’s flying in this afternoon and will be here
later.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Oh,
well I guess I’ll meet her later. I’ll check on him this evening,” I added and
I left to attend to other sick people.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">A
few hours later a message came to call the ICU regarding lab results.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Jeremy’s
hemoglobin has dropped to seven,” the nurse reported, “and his heart rate is
125. Blood pressure is 100/60.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Give
him two units of Packed RBC’s,” I ordered.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Looks like he’s going to need
surgery. I hate operating on the liver.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">That
was the truth. I loved operating on the biliary system, pancreas and everything
else around the liver, but the liver itself was one of my least favorite organs
to work on.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe
it’s because you can’t really take it out. Every other intra-abdominal organ
could be removed if necessary, its functions then assumed by other organs or
replaced with medication. The esophagus can be replaced by a segment of colon
or even small bowel, stomach can be reconstructed, much of the bowel can be
resected with impunity, dialysis can replace kidneys if necessary, there is
insulin and enzymes for the pancreas, but the liver is different.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">No
other organ does its job. It metabolizes and excretes bilirubin, detoxifies
noxious chemicals releases glucose along with so many other functions. Liver
transplant is the only real viable alternative if a liver fails or has to be
removed. I was not really anticipating having to remove all of Jeremy’s liver,
but the point is that the bleeding needed to be stopped and sometimes this can
be problematic when dealing with the liver.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
considered repeating his CT scan, but decided that this wouldn’t change the
inevitable. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">So
the blood transfusion was started and he was scheduled for surgery. It was six
thirty when I went to explain the situation to his parents, both Mom and Dad
now present.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You
let him ride in the rodeo. I told you to stop it,” I heard Mom hissing loudly.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“He’s
an adult. I can’t live his life,” Dad replied in more of a whisper.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You
could if you were more of a man,” Mom answered, the hissing growing louder.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
took that moment to interrupt and introduce myself to Mom. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I’m
Dr. G, I’m pleased to meet you,” I began, addressing Mom. “I think you know
that Jeremy needs surgery. I’d hoped he would stabilize, but that hasn’t
happened.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’d
like to send him to the Med Center,” she stated.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“That
would be fine with me,” I answered, “but he’s not stable at the moment. He
really needs to go to surgery. I think we’re just about ready to start.
Afterwards, when he is stable, we can try to arrange for a transfer.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She
looked at me with an expression which said, “You better take care of my Jeremy
or else…”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
left the worried family and met the OR crew as they began to wheel Jeremy down
the hall from ICU to the OR.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Don’t
worry,” I reassured him, “we’re going to take good care of you.” This has been
my standard line to worried patients over the years, short and to the point,
but very effective.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Jeremy
was fairly stable as I made my long midline incision. His heart rate was 120,
BP 110/60.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Upon
entering the abdomen I was greeted by blood, blood and more blood, dark blood
wafting up from between loops of slightly pale bowel. There was more blood
around the liver, redder, fresher along with large congealed clots.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">We,
that is myself and my assistant, scooped out all the blood and began by packing
“laps” all around the abdomen, starting with right upper quadrant around the
liver, then around the spleen and in the lower abdomen.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The money is on the liver. At least I
don’t see a lot of active bleeding. <o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
pulled the packs from the lower abdomen. This area was pristine, no active
bleeding, no hematoma. Next I “ran the bowel” which means I checked the small
bowel from its beginning at the Ligament of Treitz until it terminated in the
cecum. No injury. The packs were pulled from around the spleen. The left upper quadrant
was also spotless; without bleeding or injury.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Time to work.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
gingerly removed the packs from around the liver. There was adherent clot over
most of the right lobe with a laceration into the parenchyma and a small amount
of oozing of red blood. The capsule of the liver had been disrupted over most
of the right lobe.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe just leave a drain? No, he’s
been bleeding. I definitely need to do something. <o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
left the clotted blood which coated the denuded liver surface in place and
approached the laceration. This was a crevice which ran from the superior right
lobe laterally and inferiorly. Bright red blood was slowly welling up and then
running down the liver’s surface. Carefully, carefully I put my hand behind the
liver and gingerly lifted the right lobe, this brought the laceration closer to
me so that I could actually see what I was doing. I packed laps behind the
liver which helped hold it in place. I divided the right triangular ligament,
which is a peritoneal attachment holding the right lobe. This allowed me to
bring the laceration even closer. Now I could see into the depths of the liver,
clean out the clot under direct vision, find what was bleeding and stop it, <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I hope.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
began by washing away the clot, irrigating it with saline, doing my best to
cause as little disturbance as possible so as not to stir up new bleeding.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">What’s happening?</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">My
thoughts preceded my words.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Is
there a problem?” I asked the anesthesiologist. “All of a sudden everything is
bleeding.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Indeed,
the surface of the liver was now a continuous ooze of blood which was filling
up the belly. The laceration was briskly filling up with bright red blood. The trickle
had become a flood.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Nothing’s
changed…wait, how did that happen?” the anesthesiologist replied.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“How
did what happen?” I inquired, a sense of urgency in my voice.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“His
temp is 93.5. I’ve only given him 2 units of blood, but something has caused
his temp to drop. I don’t know how long it will take to warm him.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">How did he get so cold? Maybe a
transfusion reaction? Just pack him for now, get him warmed up and then come
back and fix the problem.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
commotion at the head of the table faded away as I tuned out everything and
concentrated on the problem at hand.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Laps,
a bunch of them,” I ordered, the level of my voice rising only slightly.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
packed laps into and around the lacerated liver, holding pressure and then
packing more until they stayed dry.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
closed his belly quickly and we rolled him back to the ICU. His blood pressure
was 100/60, heart rate 110, temp 93.7. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
rushed through the immediate post op tasks of dictation and orders and then
went to face his worried family.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
found Mom and Dad in heated discussion.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Would
you believe it?” Mom stated as she turned to me. “Wonder man here has an
insurance plan that doesn’t cover ‘animal related injuries.’ What kind of
insurance is that?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“One
of the questions was about animal related activities,” he replied, a bit
sheepishly. “I couldn’t lie.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“That
is not a concern at present,” I said. “Worry about that later. Right now I have
some news for you. I guess you can tell that I’m out of surgery. We had a bit
of a problem…”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Jeremy’s
OK isn’t he? He better be OK,” Mom almost threatened.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“He’s
OK, at the moment, but as we were working he started bleeding more, bleeding
from places that should not have bled. His blood wasn’t clotting. I did what I
could do to control everything, but he’s still not out of the woods and I’m not
a hundred per cent sure what the problem is.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“How
is he now?” Dad asked, his voice filled with nothing but anxiety and worry.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“He’s
stable, blood pressure is normal, all his organs seem to be functioning. It
looks like his body temperature dropped and blood doesn’t clot well if you’re
cold. We’re doing what we can to warm him and make sure there are no other
clotting problems. I packed a bunch of surgical pads around the sites which
were bleeding and that has controlled everything, at least for the moment. He will
need to go back to surgery in about 48 hours to remove them. In the meantime we
need to correct his temperature and any other abnormalities. And, hope he doesn’t
bleed anymore.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">But,
he did continue to bleed. Besides his low body temp, his coagulation studies
were abnormal. Most likely everything was intertwined. Blood clotting is a
complicated series of events which starts with platelets plugging a hole in a
blood vessel, followed by a cascade of enzymatic reactions which lead to a
mature clot. Biochemistry teaches us that such reactions work best at normal
body temperature. Significant lowering of body temperature causes derangement
of normal clotting. And, once a body starts oozing it tends to beget more oozing,
sometimes leading to the flood I witnessed within Jeremy’s belly. Thus, my
decision to pack around the site of bleeding and stem the tide for the moment. This
action, I hoped, would buy time to correct the underlying problem.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
worked, at first. I checked his coagulation status. His PT was elevated at 22
and his PTT was 48. His platelets were OK at 110,000. The nurses were working
on warming his with a heating blanket and warmed fluids. He was transfused two
jumbo units of FFP, plasma which would replace the clotting factors which had
been consumed. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe he’s out of the woods.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">But,
eight hours later, at four in the morning, his heart rate started to rise, his
blood pressure dipped and his hemoglobin dropped from 10 to 8. There were a few
bright spots. His body temperature was normal and his PT was down to 17 and PTT
was normal.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Transfuse
two units PRBC’s and give another jumbo unit of FFP,” I ordered. “I’ll be in to
see him.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">What to do? What to do? There must be
some blood vessel which continues to bleed. Should I operate again? I’ve
already been there. Maybe, maybe there’s a better alternative? Yes, there is another alternative which might
work. I hope Dr. L. is on call.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">My
plan was simple. Rather than dig through the injured liver looking for the
source of bleeding, the problem would be approached from a different angle. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I
know you don’t like to get up early, but I really need your help,” I explained
to Dr. L. I told him the whole story.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Do
you think you can do an arteriogram and embolize whatever hepatic artery is
bleeding?” I finally requested.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“It
might work,” he concluded, “although I’ve never embolized for this type of
injury before.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
was true. Angiography and embolization of arteries for trauma is commonplace
these days, 25 years ago such a practice was sporadic.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
called Jeremy’s Mom and Dad and explained his condition and the plan.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">An
hour later he was wheeled down to the angiography suite.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
stretched out on the couch in the doctor’s lounge.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe I should go home and sleep for
a couple of hours. With my luck I’ll get called back as soon as I walk in the door.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
closed my eyes for a few minutes, until I was interrupted by a call from Dr. L.
<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“There
was a tiny blush from a branch of the right hepatic artery. I did a
subselective embolization of the right hepatic. I think he’ll be better,” Dr.
L. reported.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Thank
you,” was all I said.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Six thirty. I guess I’ll make rounds
and then check on Jeremy.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Jeremy
did stabilize. His heart rate came down to 95, BP stayed around 110/60, he was
awake and alert, talking, wanting to eat.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Clear
liquids for now and we need to take you back to surgery tomorrow to remove all
those packs,” I reminded him and his parents.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
scheduled the next procedure for the next day to be done around 4 pm.
Unfortunately, I was on call and had to deal with a perforated ulcer before
tackling Jeremy. It was around 7 pm when the OR crew came to pick him up.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’ll
be out to talk to you as soon as I’m done I reassured Mom and Dad and a
multitude of other relatives and friends.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Could
you talk to another doctor on the phone” Mom asked.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Really, do I have to?<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Another
relative?” I asked, a bit facetiously.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“It’s
Dr. Red Duke,” she added.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Oh,
OK.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Dr.
Red Duke was a local celebrity. He was a general surgeon at the Texas Medical
Center, was regularly featured on local news shows where he would explain a
variety of medical and surgical maladies and what to do about them. Outside of
that I really didn’t know him.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Hello,
this is Dr. G.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“This
is Dr. Red Duke,” he answered in his thick Texas drawl. “Tell me what you’re dealin’
with thar, young fella.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
presented the case as succinctly as I could and he listened without interruption.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Sounds
like you’ve done a fine job, doctor. My only advice is that when you remove
those lap pads, soak them in peroxide first. If you do that, they won’t stick
and you won’t stir up any new bleeding. Good Luck.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Thank
you, now I think they’re waiting for me.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
hung up and headed to the OR where they really were waiting on me.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Sorry
to keep you waiting,” I explained, “but I had to get some advice from Dr. Duke.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You
mean Red Duke.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Sho
‘nuff,” I answered in my best Texas accent, “the family called him. Now let’s get
this done with.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">This
return to OR was most uneventful. There was only a couple hundred cc’s of old
dark blood, the packs easily came out after soaking them with saline and there
was no bleeding. The abdomen was washed out, I left a drain by the liver and
closed him up. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe I can get a full night’s sleep.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">No
such luck. I was in bed by ten, but at 1:00 the phone rang.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Jeremy
is very short of breath. He’s breathing at about 36 (normal 12-16), his oxygen
saturation is 90% on 100% nonrebreather, heart rate is 120, BP is high at
150/95.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’ll
be in to see him.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I’m getting tired of this.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">For
the third night in a row I climbed out of bed and made the twenty minute drive
to the hospital.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Jeremy
was sitting upright in bed, his oxygen mask in place, breathing at a rate of
about twenty eight. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“What’s
going on, Jeremy?” I began. “Any pain?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Just
feel winded, like I can’t get enough air into my lungs.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">His
oxygen saturation was at 91%, heart rate was 120. BP, urine output were OK. His
chest X-ray looked a bit congested and there were bilateral pleural effusions,
which means fluid around his lungs.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Do
you think we need to intubate him, Dr. G?” the ICU nurse asked.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Give
him some Lasix, 40 mg, now. I’m going to talk to Pulmonary.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
called Dr. P. and told him the story, while Jeremy got the Lasix.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Dr.
P. will be in,” I told the nurse, but I could already see improvement with the
Lasix.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Jeremy
put out about 4 liters of urine. His breathing calmed and he began a steady
improvement. His bilirubin rose to about 6, possibly related to the
embolization of his liver, but then came down to normal.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">There
was no more bleeding, no respiratory difficulty, he was soon up walking and
eating and he went home about twelve days after the original injury.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
control of bleeding utilizing angiography and embolization was a technique I
had used prior to Jeremy, primarily for bleeding secondary to pelvic fractures
and bleeding from tumors which could not be accessed surgically. The technique
now is more common, often being used for trauma to the spleen, as well as liver
and the aforementioned pelvic fractures. It is a true life saver in those cases
where the patient has an isolated injury to an organ which will tolerate the embolization.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
liver has a dual blood supply, receiving blood from the hepatic artery and the
portal vein. In this case, embolization of the artery did the trick.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
saw Jeremy about four years later. He came to see me because he thought he had
a hernia. He had given up riding in the rodeo and was working locally as an
electrician. He did not have a hernia.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">His
Dad paid me ten dollars a month for a couple of years, determined to make up
for the lack of insurance. I told my office staff to write off the balance and
forgive the rest of his debt after about two years.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
stay away from horses, except for the occasional trips to the race track.<o:p></o:p></span></div>
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David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-54460638926289305842016-02-21T19:30:00.002-08:002016-02-21T19:30:44.275-08:00Why Did This Happen?<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
was a Whipple. Not Mr. Whipple of Charmin fame, but the operation which carried
the name of Whipple. The proper name is Pancreatoduodenectomy and it is a
procedure which most surgeons decline to undertake.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Named
for Allen Whipple, the operation consists of removal of the gallbladder, a
portion of the common bile duct, the head of the pancreas and the duodenum with
the most proximal jejunum. In its original form it was performed in 2 stages,
first the resection and then, the following day, the reconstruction. It is an
operation for tumors in the head of the pancreas, distal common bile duct and
duodenum. Occasionally it is utilized for benign strictures of the distal bile
duct, often due to chronic pancreatitis.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">To
me the operation presents a study in anatomy and an exercise of careful
dissection. The portal triad, consisting of bile duct, hepatic artery and
portal vein must be teased apart, vessels to the liver preserved and the
pancreas gently lifted off the superior mesenteric and portal vein.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Mark
needed such an operation.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Mark
was 52 and came to the hospital because he had turned yellow. He had noticed
the color change for about two weeks. He also felt weak, had vague abdominal
discomfort and had lost about fifteen pounds. In the Emergency Room he was
found to have gallstones, dilated bile ducts and “focal” pancreatitis on CT
Scan of the abdomen.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">His
bilirubin level was 12, which is why he looked yellow. Normal bilirubin level
is under 1.0. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Fortune
put me on call for the ER that day and I was consulted by Mark’s admitting
physician. His presentation was not typical of gallstone pancreatitis. His pain
was mild. The bilirubin was too high, weight loss did not go along with acute
pancreatitis.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">And,
when I reviewed his CT Scan, the finding of “focal” pancreatitis looked like a
tumor to me and to another Radiologist colleague with whom I was reviewing the
images.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Further
work up with MRCP revealed the stricture in the bile duct and a definite mass
in the pancreas.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Mark
needed a Whipple. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">He
was otherwise healthy. The surgery was scheduled for two days later.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">At
9:08 am on a Tuesday I made my chevron incision in Mark’s upper abdomen, dealt
with the usual bleeders in the abdominal wall and entered his peritoneal
cavity. There was no fluid, usually a good sign, the liver was discolored from
his jaundice, but free of any masses. Palpation of the head of the pancreas
revealed the expected hard mass, a sign of either inflammation or tumor.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Next
came the first decision. Should I biopsy the pancreas? Would such a biopsy
change anything? Suppose the biopsy revealed cancer. The treatment would be to
resect the tumor, that is, to continue with the Whipple procedure. But, suppose
the biopsy only revealed inflammation, or fibrosis, without any tumor? The answer
is that it wouldn’t make a difference. Mark still needed the Whipple.
Pancreatic cancer is a funny beast. It causes an intense fibrotic reaction. The
tumor often is obscured by this fibrosis and diagnosis, particularly on
intraoperative frozen section is often very difficult. Mark’s presentation was
textbook cancer of the pancreas. Even if his jaundice turned out to be benign
disease, which was unlikely, the proper treatment was still the Whipple.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
first decision was, therefore, simple; no biopsy.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Next
I removed the gallbladder. It contained a bunch of stones, but otherwise wasn’t
inflamed. It was in the bucket in about ten minutes.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Time to get going.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
<b><i>Kocherized</i></b>
the duodenum, which meant I divided the peritoneal attachments of the duodenum
which allowed me to lift the pancreas and duodenum off any underlying
retroperitoneal structures. The main structure of concern was the Inferior Vena
Cava. I was now able to hold the entire head of the pancreas in my hand. The
mass felt hard, while the neck felt soft and spongy, the way normal pancreas
was supposed to feel. I mobilized as much as I could, until I could feel the
pulse of aorta adjacent to the pancreas.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Time to tackle the porta hepatis.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">This
part of the operation is the time to be careful and methodical. The common
hepatic artery arises from the celiac axis, a major branch from the aorta. This
common hepatic artery branches into the proper hepatic artery which is one of
the major structures of the porta hepatis and supplies arterial blood to the
liver, and the gastroduodenal which supplies the duodenum and the pancreas, but
also gives rise to the right gastric artery which is important to preserve in
the so called pylorus preserving Whipple which is what I planned for Mark.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Carefully
I exposed the arteries. It turned out to be one of the easier dissections of
these structures I’d ever performed. There was considerable space between the
common bile duct and the arteries, making separation of these structures very
straightforward. All the branches were dissected and encircled with silk ties,
but none of these arteries were divided yet. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Next
the bile duct was identified, dissected free and also encircled. It was dilated
to about 1.6 cm, about twice normal size. Behind the bile duct was the portal
vein, usually the make or break structure in Whipples. This large vein is
formed where the superior mesenteric vein and splenic vein meet. It abuts the
head of the pancreas and tumors often grow into and around it, which renders
these tumors unresectable, at least for cure. The anterior surface of the vein
is dissected free so that the neck of the pancreas can be lifted off the vein. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Mark’s
portal vein easily separated from the pancreas. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Once
all this dissection being done it was time for the real operation to start.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
gastroduodenal artery was ligated and divided, while the proper hepatic and
right gastric arteries were preserved. The bile duct was also transected, an
act which always fills me with an oxymoronic combination of fear and delight.
This unusual feeling is due to the repeated drilling during residency to “know
where the bile duct is, do not injure the bile duct,” every time a gallbladder was
removed.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Next
the neck of the pancreas is lifted off the portal vein and divided, vessels
running with this organ are sutured as there is always some bleeding. Great
care is taken to not suture the pancreatic duct.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
portal vein is now separated from the pancreas. There are always a number of
small branches running from this vein into the head of the pancreas. Each is
dissected free, clipped and divided.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
jejunum, just beyond the ligament of Treitz is divided and the vessels going to
the distal duodenum are divided, mostly using my trusty “Ligasure” device. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Finally,
the uncinate process of the pancreas is freed from the its connections posterior
to the portal vein. Mark had an unusually large collateral vessel in this area
which required special attention to control. The vessel was feeding into the
pancreatic mass and could not be preserved. I always worry when I find, and
sacrifice, an unexpected and unusually large artery; worry that it might be
important. In Mark’s case I my worries were well founded.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">These
final maneuvers completed the resection and the specimen: head of the pancreas,
duodenum and portion of bile duct was handed off to the circulator who passed
it on to Pathology for immediate examination.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Looks
like adenocarcinoma of the Pancreas,” the friendly neighborhood Pathologist
reported, “margins are free.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Thank
you,” I replied and I set about the task of reconstructing the damage I had
created.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">At
this point in the operation what I have is the divided pancreas, bile duct and
duodenum. These organs are designed to meet at the Ampulla of Vater where bile
and pancreatic juice are dumped into the duodenum to join and digest ingested
food. The task at hand is to reconnect each structure to the intestine to
restore the normal digestive function. Connecting the Pancreas to the bowel is
considered the Achilles heel of the Whipple procedure. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Back
to work. The divided pancreas was dissected free a bit more which allowed me to
put the about three centimeters of the divided pancreas inside the small bowel.
Sutures of 3-0 Prolene were used to suture the thin, weak capsule of the
pancreas to the bowel. Sometimes the pancreas is more fibrotic and will hold suture
fairly well. Mark’s pancreas was more normal and the sutures held, but I knew I
was going to worry for a few days.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
bile duct was next, an anastomosis using 4-0 Vicryl in a single layer,
straightforward and uncomplicated.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Finally,
the duodenum, just beyond the stomach, was anastamosed in 2 layers to the small
bowel, using 3-0 Vicryl and 3-0 silk. Drains were placed, the belly closed and
he was brought to the recovery room.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Mark
was very stable for the first 24 hours. There was slight tachycardia, heart
rate around 105, but nothing else unusual. The two drains put out
serosanguinous fluid as expected and the volume of fluid put out was low.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Labs
on the first day revealed a bilirubin of seven, down from thirteen preop. His
white blood cell count was high at 21k, but this is not uncommon with the
stress of such a major operation. His hemoglobin level actually was higher than
preop.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Hemoconcentration, very common after
Whipples.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
increased his fluids and went on my way. That evening I made my usual call to
the ICU to check on Mark and my other ICU patient.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“He’s
more tachycardic now, heart rate 130,” his nurse reported. “Urine output is OK
and oxygen saturation is 100%. He looks comfortable.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Give
him a fluid bolus, a liter of lactated ringer’s,” I ordered and I went to bed.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
didn’t hear anything more that night. I saw Mark first thing the following
morning. His heart rate still was hovering around 130. His WBC was 20k, he had
a mild metabolic acidosis and his renal function was a little worse.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
ordered a stat CT of the abdomen and gave him more fluid and antibiotics.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">What’s wrong with Mark?</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">His
drains weren’t putting out very much and the fluid was the expected
serosanguinous. The NG tube was bile, his abdominal exam was unremarkable. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Everything looks OK, except for him.
Maybe the CT will help.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
CT was finished later in the day: Post op changes, no fluid collections, nothing
that would explain Mark’s persistent tachycardia and elevated WBC.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe he’s just one of those patients
who becomes tachycardic under the stress of surgery.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Over
the years I’ve had a handful of patients whose heart rates go up for a few days
after surgery, even after a relatively minor procedures. For example, one young
woman had excision of a retroperitoneal node to diagnose lymphoma. She
maintained a heart rate in the 120’s for five days afterwards. The resident
staff, including me, scratched our collective heads and searched for an
etiology. None was ever found and her heart rate eventually became normal and
she went home. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Unfortunately,
this was not the case for Mark. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
next day I noticed that one of his abdominal drains now was putting out bile.
Even worse, Mark was tachypneic, respiratory of 36. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">He’s septic. I need to take him back
to surgery.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
expected that he had a leak from the pancreatic anastomosis. What I found was
very unexpected.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">There
was bilious fluid in the abdomen, as I anticipated, but the some of the bowel
was dead. Specifically, the loop of small bowel which I had used to reconstruct
the GI tract was necrotic, about forty centimeters. The small bowel beyond the
duodeno-jejunostomy was pink and viable. In addition the right colon didn’t
look right.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
began by taking down each anastomosis. The pancreas, bile duct, stomach and
duodenum all looked OK, well perfused and essentially healthy. I resected the
gangrenous bowel and redid each anastomosis. The pancreas was even more difficult
to handle, due to the surrounding inflammation and edema.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe I should ligate the pancreatic
duct and not do a pancreatic anstamosis? Or, maybe remove the rest of the
pancreas?<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">There
were plus and minuses on each side. Ligating the pancreatic duct likely would
preserve the pancreatic endocrine function and prevent Mark from becoming a
very brittle diabetic, but would also likely lead to pancreatitis which could
be severe. I wasn’t sure Mark would survive a bout of rip roaring pancreatitis.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Removing
the pancreas eliminated the risk of pancreatitis, but would leave Mark with
pancreatic endocrine insufficiency, which meant diabetes which could be
difficult to manage as well as the need to take supplemental pancreatic enzymes
for the rest of his life.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">In
the end I redid the pancreatic anastomosis, wrapped it with omentum and put
drains all around it. The bile duct and duodenal anastomosis were
straightforward. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
looked at the right colon again.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It looks dead.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Fifteen
minutes later this part of the colon was sitting in a bucket and I was creating
an ileostomy.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Finally
finished, Mark was deposited in the ICU where his overall condition improved
immediately. His heart rate came down, his bilirubin came down, he maintained
his blood pressure, renal function remained stable and the drains were only
putting out serous fluid.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Still,
a question nagged at me.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Why
did Mark develop this devastating complication?<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
wish I knew. I’ve postulated that the unusually large vessel which was
supplying the pancreas may have also been the major arterial supply to the
proximal small bowel. The colon gangrene I chalked up to low flow and
vasoconstriction, although it is possible that sacrificing that vessel also
affected the colon. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Perhaps
the middle colic artery, which is the major blood supply to the right colon
took an anomalous course adjacent to the pancreas. Maybe the mesentery twisted
causing the gangrene, although it didn’t look this way at the second operation.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
never found out for sure. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
had planned to return Mark to surgery 48 hours later, to examine the bowel for
further ischemia and necrosis, but his overall condition so dramatically
improved that I cancelled this procedure. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
also wish I could say that Mark made a 100% complete and uncomplicated
recovery, but this was not the case. He improved for about ten days. But, on
the eleventh day he started putting out more fluid from one of the drains
adjacent to the pancreatic anastomosis. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">He
required prolonged support on a ventilator, dialysis for a time and TPN. He had
this fistula for about three months before it finally healed and he was able to
get on with his life.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">His
pathology revealed adenocarcinoma of the pancreas, no spread to any lymph
nodes. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
hope he is cured.<o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-1409626910333344622016-02-06T10:12:00.000-08:002016-02-06T10:12:43.877-08:00Med School Memories<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14.0pt;">The first year of Medical
School was a jumble of lectures and labs punctuated with brief encounters with
actual live patients.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;"> There was the half day at one of the local
Emergency Rooms where I was joined by a fourth year student. I'd been in med
school for about three weeks. I had become well versed in the anatomy of the
back muscles and the histology of the liver and spleen, but I knew nothing of
authentic diseases or their treatment.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-align: justify; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">We met
one of the ER Attendings, an Internist, and I was treated to a few hour of medical
heiroglyphics. We were quizzed on the therapy for urinary tract infections, a
pretty simple question. As I began to answer, the fourth year spouted off a
litany of different antibiotic choices, drowning out my suggestion of
Penicillin. At that time in my medical career I thought penicillin was <b><i>the</i></b>
antibiotic and was effective treatment for any and all infections. This may
have been true in 1945. But, it was now 1980 and the list of antibiotics was
growing longer everyday. I stayed quiet for the final few hours, listening and
learning rather than demonstrating my ignorance.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">My next
encounter with real patients was a four week elective in Urology, myself along
with two of my classmates. Our instructor was Dr. Leake. We also had two
sessions with Dr. Cockett. Leake and Cockett. Can you think of two more appropriate
names for Urologists? One of the highlights of these four weeks was visiting
Mr. Godfrey.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">Poor
Mr. Godfrey had cancer of the prostate and was receiving combined Radiation and
hormonal therapy. We saw him twice a week and each time Dr. Leake wanted us to
do a rectal exam on the unfortunate Mr.
Godfrey. Without even a sigh Mr.Godfrey turned on his side and suffered through
this biweekly ritual. The last session of this elective finally came which
meant the last four rectal exams Mr. Godfrey would have to endure. We all
arrived sporting those big "We're Number One" gloves frequently seen
at sporting events.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">“OK,
Mr. Godfrey, time for your rectal exams.” We chimed in unison.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;"> Dr. Leake was not amused, but our patient had
a nice chuckle.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">There
were no other memorable clinical encounters until the third year. The entire
class eagerly began “General Clerkship.” Four weeks were allotted to teach us
how to talk to, listen to and touch the, up until now, sacred creature called, “The
Patient.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">We
were told to let the patient talk, to listen actively and guide the patient
down the history road so that they would impart as much information as
possible. We were taught how to guide a rambling patient back to the clinical
road which lead to the formulation of the all important “Differential
Diagnosis.” Thus, it was emphasized over and over, the history would guide the
next steps of a patient’s evaluation.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">We
discussed the philosophical and practical concerns along with the grave
responsibility that accompanied the “Laying on of Hands.” The actual physical
exam meant bursting through societal taboo’s against penetrating another
individual’s personal space, sometimes invading their most personal and
intimate parts, always towards the goal of healing. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">“Just
the act of physical touching may be beneficial to your patient’s wellbeing,” one
psychiatrist lectured.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">We
were treated to Dr. L demonstrating a complete physical exam (except rectal and
pelvic) on one of our classmates. He spent about forty five minutes observing,
palpating and auscultating, in the end declaring:<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">As you
can see, this complete physical need not be an all day affair.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">In our
more modern times, when a primary care physician may see 50-60 patients a day,
performiong a forty five minute exam on each patient would make for a very long
day indeed.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">We all
waited with fear and trepidation for the “Pelvic Day.” This was the day when
each student would receive indoctrination into the intricacies of the female
pelvic exam. Professional models were hired, each set up in a private cubicle
where the student was given about ten minutes of monitored probing.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">“My
uterus is retroflexed,” my model reported, “so you would need to do a rectal
exam to properly feel it. You should be able to feel each ovary however.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">“Until
you’ve done about two hundred pelvic exams you may as well be waving your
fingers in the wind,” Dr. A, one of our instructors, commented.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">Finally,
the last pieces of the physical exam came up: the aforementioned rectal exam
and the male genital exam. These we did on each other.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">“Never
go to a Proctologist who can palm a basketball,” one instructor joked.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">“You
should be concerned if you feel both your examiners hands on your shoulders
during a rectal exam,” another quipped.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">“All in
good fun to lighten the tension,” they said.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">Maybe
they should have volunteered to be subjects… all in the name of education, of
course.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">Finally,
we were finished with general clerkship and were ready to be set loose upon the
unsuspecting patients of Rochester, New York.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">“Go do
an H&P on the new admission in 612, a Gertie Black, CHF,” my third year
resident ordered.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "times new roman" , serif; font-size: 14pt;">Ready or not here I come, Ms. Black<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">I
perused the chart of patient Black before venturing into see her. I glanced across
the nurse’s station into her room and caught a glimpse of my new patient. She
was about five feet tall and five feet wide. At the precise moment I looked
over at her she bent over. Her hospital gown did little to cover her ample
assets and I was treated to a “full moon over Rochester.” So went my
introduction to clinical medicine at Strong Memorial Hospital in Rochester, New
York.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">It
wasn’t long before I was churning out 10-15 page H&P’s on a daily basis. The
history part, the H, was not a problem. Ask the right question and listen. My
patients had no qualms about opening up to me, revealing the darkest secrets of
their lives.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">“I…
like… to smoke… a few… joints… every day… well… several… times… a day,” Mr. M.
confided. He had been doing this for most of his seventy years. His very measured,
deliberate speech no longer was a surprise.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">“I
prefer women’s underwear,” another man confided. “It’s more comfortable.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">“I put
my cat in the drying machine when I was seven,” an elderly woman reported. I
really didn’t think it was relevant to her having hemorrhoids, but one never
knows.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">“I
drink a little every day, maybe three beers a day, and a couple of glasses of
wine, and I have two martinis after dinner and a brandy at bedtime,” a
councilman confessed.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">And so
it went.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">The intricacies
of the physical exam, the P, were more of a challenge.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">As a
class we shared our interesting heart murmurs, palpable lumps and bumps,
hernias, rales, rhonchi and wheezes. Gradually, I thought I was developing some
physical exam proficiency.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">Then
came my day. I was chosen to present to Dr. M on rounds. My patient was Cora,
sixty years old, with COPD and Congestive Heart Failure, admitted with
shortness of breath. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">I
questioned her every way I could, going back to her childhood days, looking for
any every possible contributing factor to her severe COPD. I tried to
anticipate any and all questions.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">I
examined her from top to bottom and then bottom to top. She had a barrel chest,
an S3, mild JVD, expiratory wheezing and, I decided, a right ventricular heave.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">I wasn’t
really sure about the right ventricular heave. A definition follows:<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">“When
there is pulmonary hypertension, the Right ventricle has to overwork, it has to
pump against the increased pressure in the lungs. So if the heel of the hand is
placed immediately lateral to the LEFT sternal border, one can feel the right
ventricle being pushed anteriorly. The heel of the hand is lifted off the chest
wall with each systole, and this is the heave.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;"> I’m still not sure if I felt anything. But, I
read it was associated with severe COPD and poor Cora certainly qualified. I
convinced myself it was present. And, this was my chance to impress the
Attending staff.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">My
moment came.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">“Cora
is a sixty year old female who was admitted to the hospital complaining of
shortness of breath…two packs of cigarettes a day for forty years…distant
breath sounds bilaterally…right ventricular heave…being evaluated for lung
transplant.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">Silence.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "times new roman" , serif; font-size: 14pt;">I’ve done it. There speechless. I’m sure
they’ve never been so dazzled by a med student.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">“Dr.
Gelber,” Dr. M began, “could you demonstrate how one examines a patient and
determines the presence of a right ventricular heave?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "times new roman" , serif; font-size: 14pt;">Wait, I know this. <o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">“Good
morning, again, Cora,” I greeted her as I moved to her bedside. “I need to check your
chest.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">“Whatever
you need to do, Dr. G,” she turned to Dr. M. “Dr. G’s a good doctor. He spent
an hour with me yesterday, just listening and checking me. It’s OK, go ahead
and do what needs to be done.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">I put
my hand alongside her sternum. Unfortunately, I put it on the right side and
felt nothing.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">“I’m
not sure it’s there,” I murmured softly.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">“It
would probably help if you put your hand in the proper spot,” Dr. M. observed.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">“Oh,
yeah,” I stammered, even more softly. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">I
moved my hand to the proper spot and still felt nothing.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">Dr. M.
moved in. he put his hand along the left sternal border, watched her breathing
and then turned to our group.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">“Definitely
no right ventricular heave,” he announced. “Maybe, Dr. Gelber, you should be a
surgeon.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "times new roman" , serif; font-size: 14pt;">A seed
was sown.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<br />
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-88220761361216417282016-01-06T19:47:00.000-08:002016-01-06T19:47:13.918-08:00A Sweet Man<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">So far, classic gallbladder disease with episodes of
biliary colic.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Physical exam revealed scleral icterus and not much
else. Specifically, there was no abdominal mass and neither the liver nor
spleen was enlarged.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I scheduled Adrian during my regular operating time,
which was on Thursday, three days hence. I notified the Chief and thought
everything was set.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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 <b><i>he</i></b> 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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">He was not happy.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I cancelled an important meeting to do that surgery.
Do not <b><i>ever </i></b>take me for granted. Change it back,” he almost shouted,
the first and last time he ever raised his voice at me.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.” <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Such help I did not need.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">And he smiled his sweet smile.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Thank you, thank you,” he responded and his smile
grew even larger.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Clean floors,” he told me through an interpreter, “are
important to a hospital. My floors are the cleanest.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">And, I believed they were.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The question was: “When should I bring it up to the
Chief?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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 <b><i>him</i></b> would be foremost in
all our minds.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Finally, Adrian’s big day came.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Looks pretty obvious, don’t you think Chief?” I
asked, pointing to the bile duct.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You still need to follow the rules,” he responded.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I know, I was just testing you,” I shot back; he
smiled at me.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe
this won’t be too difficult. Be careful. Don’t say anything or you’ll jinx yourself.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> The Chief
inserted this scope through the opening in the bile duct and then handed the
scope to me. A stone was clearly visible. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“There are more in there,” I commented.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Keep at it,” the Chief replied.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Five more stones were removed and there was at least
one more.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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,<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’ll try a Fogarty,” I decided and the Chief nodded
his head in concurrence.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“If this is what I have to look forward to in Heaven,
I hate to think about the alternative,” I quipped.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The Chief gave me a look of frustration, then asked, “What’s
your plan now?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You wouldn’t consider a transduodenal sphincteroplasty?”
He asked, playing Devil’s advocate I suspected.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 0in; text-indent: 1.0in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 0in; text-indent: 1.0in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 0in; text-indent: 1.0in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
Chief agreed.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 0in; text-indent: 1.0in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 0in; text-indent: 1.0in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">While
suturing away I asked the Chief about Adrian.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 0in; text-indent: 1.0in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 0in; text-indent: 1.0in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 0in; text-indent: 1.0in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">And
that was that. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 0in; text-indent: 1.0in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 0in; text-indent: 1.0in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 0in; text-indent: 1.0in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">He
gave me his big smile and his eyes shone. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 0in; text-indent: 1.0in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’ll
be there,” he answered and he smiled again.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 0in; text-indent: 1.0in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Wait,
before you go the Chief wants to say hello,” I added.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 0in; text-indent: 1.0in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
Chief came from the back and shook Adrian’s hand.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 0in; text-indent: 1.0in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Good
luck, Adrian,” was all the Chief said and he walked away.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 0in; text-indent: 1.0in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">However,
I did hear him murmur, “such a sweet man.”<o:p></o:p></span></div>
<div class="MsoNormal">
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David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-44293147178296900932015-12-25T14:49:00.002-08:002015-12-25T14:49:46.319-08:00Surgical Dilemma Part Three<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">For
the moment, I was unemployed. However, my little book, “The Amazing Journey,”
continued to be a hot seller, thanks to Annabelle and a thousand positive
reviews. Sales passed 250,000 which made me number one among all books about
surgery, number five on the nonfiction list and promised to put more than half
a million bucks in my pocket. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Even
though it looked like I would be financially secure, I was more than troubled
by my recent disaster. I did call the hospital to speak with Art Shaw, the
current Chief of Surgery.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Take
some time off while we investigate. You’re not officially suspended or
anything, but it would be best for you to keep a low profile until we talk to
all the parties involved. Just take a vacation for a few weeks. You deserve it
anyway,” he advised.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
did my best to follow his recommendation.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
took the dogs for a couple of walks every day, began a sequel to “The Amazing
Journey,” sorted through myriad offers to market it, make it into a movie or TV
show, to interview me and everything else which one could possibly associate
with a bestselling book.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">And,
like any older middle aged man going through a crisis I did the only logical
thing possible. I bought myself a Corvette. Not a red one; no mine was black, a
top of the line Z06. I considered a Lamborghini or Ferrari, but my practical
side won out and I settled for “Black Beauty.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">And
I thought about Lori, all the time. I knew she had survived the ordeal of the
accident and the greater ordeal of surgery. My contacts in the ICU kept me in
the loop, sending me daily updates on her condition. She was still on the vent,
was being dialyzed regularly, was awake at times, but she was not completely
out of the woods. The next ten to fourteen days would be most important. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
tried to visit her once. I made it through the hospital entrance, even past the
fish tank in the lobby. But, when I pushed the button for the elevator, I felt
my heart pound and sweat began to bead up on my forehead. The same contemptuous
laughter that had chased me from the OR filled my head and I turned and quickly
walked out.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Now
I spent time driving around town in “Black Beauty.” That’s when I saw her. She
was standing outside Saks, staring into her phone, probably waiting for Uber.
It was my one time circulating nurse.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Ms.
Vargus.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Alone
on that corner she did not resemble any OR nurse I’d ever known. Wind blew
through her long dark hair creating a tousled, sexy mess, her top was
sleeveless with the top three buttons open which caused it to billow out with
each gust. At the same time her dress clung to her, accenting every perfect
curve.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Chivalry
and lust forced me to pull over and render aid to this poor, suffering angel.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You
look like a lady in distress, Miss Vargus. May I offer you a lift?” I asked, my
voice wavering a bit.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She
gazed intently at my face and then into my eyes, looking like she was trying to
remember if we had met previously and then she started to answer.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I
don’t think…” she began before I interrupted.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Surely
you can trust your favorite surgeon. I did manage to bring your Boss back from
the abyss and save your skin in the process.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She
stared into my eyes and then smiled.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Oh,
Doctor…thank you. I need a lift home. My ride seems to be stuck in traffic.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Have
no fear, dear lady. I am at your service; a gallant knight to do your bidding.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She
climbed into the front seat, bending forward just enough to give me an eyeful
of her ample bosom.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Home,
driver. 1311 Elwood.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
wasn’t sure where Elwood was, but between her directions and my navigation
system I delivered her outside her apartment in just a few minutes.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Thank
you so much for the lift. I don’t know how much longer I would have waited,”
she remarked as she hoisted herself out of the Corvette. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Then
she added, “The Boss is away on business for a few days, which means my life is
nothing but an empty bore. Would you like to come up for a cup of tea?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Come up for a drink? A pickup line? Why
not. I am certainly not doing anything important.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Sure,
as long as it’s a good black tea.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“English
breakfast?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Deal.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’m
on the sixteenth floor, number 1604. The Boss is across the hall in 1601,” she
informed me.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
parked the ‘Vette” and met her in the lobby.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You
must do pretty well for yourself,” I commented as I we entered through double
doors into a huge foyer and living room. The floors were all marble and exotic
hardwood and there were floor to ceiling windows opposite the entry which
looked out over the park below.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“The
boss treats me well. His apartment is even bigger and fancier. “Now what am I
supposed to do? Oh, yes, tea.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She
disappeared into the kitchen while I settled into a plush leather couch. She
reappeared ten minutes later carrying a tray loaded with pastries, cheese and
crackers, a large teapot and two cups. She had taken the opportunity to change
into a sheer bathrobe which did a poor job of hiding her ample assets.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Try
one of the scones, they are simply to die for and the cheese is imported from
Paris,” she said as she poured out the hot water. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
put my hand on her hip and spun her around, her robe coming undone as I pulled
her down towards me.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’ll
skip the scones for now, if that’s OK with you.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Why,
of course, Doctor,” and she pressed her open mouth against mine.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
was two hours later when I finally had my cup of tea. I found a man’s bathrobe
in her closet and was staring out her window when she tapped on my shoulder and
handed me a cup of tea.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Now,
I think I’m ready for one of those special scones,” I decided.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">We
ate rich pastries and drank some fine tea and then I reached over and grabbed
her around the waist.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’m
ready for the main course now.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
was six am when I finally left her apartment. We made plans for dinner.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The dogs will be mad at me. It will
be past their dinner time.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
quickly fixed five bowls for my canine buddies and then went to the computer.
First I made dinner reservations for the two of us at Angelo’s and then I tried
to search out some information on my new love.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Lillie
Vargus,” I entered into Google. There were a lot of women with that name, but
none were <b><i>my</i></b> Lillie Vargus.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
could not find anything on her. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe I should be more trusting. Sure,
great sex is something, but she works for Satan. No harm in checking her out.
But, the sex was fantastic. Keep your thoughts above the belt.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“What’s
the name of their company? I know I saw it on the dresser by her bed…Vixen
Enterprises, that’s it.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
went back to the computer and searched for Vixen Enterprises. The company’s web
page popped up.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“International
finance, shipping, industrial investment…”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Nothing unusual. What about their
people?<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Stewart
Young, CEO, graduated Wharton School of Business. Been with company twelve
years…”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Michel
Bostick….”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Just a boring company. No Lillie, no
Satan, just a bunch of men in suits. I guess I shouldn’t be suspicious. Maybe
this isn’t even the right company. I’ll try to bring it up at dinner tonight.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Dinner
at Angelo’s was a great prelude to an even better night. Lillie was dressed in
a little black dress. Her only adornments were sparkling diamond stud earrings
and a large sapphire and diamond ring.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Gifts
from past admirers,” she explained. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“The
Boss?” I wondered out loud.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Oh,
no, that’s not his style. I work for him and that’s it.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You
know, I haven’t really met the Boss, at least not in a conscious state. So tell
me, what’s Satan like?” I asked.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Her
eyes sort of glazed over as she contemplated my question.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Satan,”
she began, but she stopped.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Satan
is misunderstood,” she began again. “Popular lore has it that Satan hates
humanity, all of mankind. This is more than unfair. The Satan I know liberated
Adam and Eve from servitude, slavery really. They were in paradise? I don’t
believe it. They toiled for a God who kept them naked and ignorant. Satan had great
foresight and freed then from oppression. Satan set them on the path which has
led to the world of today. Men and women have unleashed all the power of their
own intellect and ingenuity and have taken advantage of all the resources this
Earth can offer.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Some
would say exploited with no thought towards consequences,” I countered. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“This
world was created for humanity. Why shouldn’t all mankind be allowed to exult
in its abundance?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“But
what about death and disease, war and hunger and the evil which has been a part
of human history almost since the beginning?” I added.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Every
great advance comes at a price; that is true. But do you think god really
cares? He’s been angry ever since that first act of rebellion. A true god would
have been proud to see his children growing up, leaving the nest.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“What
about you? Has Satan treated you well?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’m
here aren’t I? I have never seen Satan hurt another person without a proper
reason or justification? Could god say the same?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I
don’t know.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
conversation had become more heated than I intended and I decided to change the
subject.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Is
your fettucine to your liking?” I asked.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
suspected she was just as anxious to change the subject.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Best
I’ve had, ever. Can I have another glass of wine?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">We
finished dinner with small talk about nothing and headed back to my place for
an after dinner drink and more. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Later
that night, as we lay in bed, I wondered out loud.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“What
would it be like to have the power of Satan, to be the Boss?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She
sat up and faced me.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Are
you serious?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Probably
not,” I answered. “Just speculating. I mean, as a surgeon, I’ve brought so many
people back from the brink of death, including your Boss. I suppose this has
given me a tiny taste of power. But the power Satan must have is enormous. I
know he’s not God, but he was given the power to rein over the earth.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She
looked at me sort of funny.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You
know,” she finally replied. “It could be done. You could take the Boss’s
place.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Really,
though, I don’t think I want to be the purveyor of evil throughout the world.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“It
doesn’t have to be evil, you know. You’re a surgeon. You help people every day,
cure them of dread diseases, cut out their cancers, mend broken bodies. You <b><i>could</i></b>
take Satan’s power and harness it for good.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“How
could such a thing be done? What would compel Satan to give up his power?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You
would have to kill him.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You
mean he has to die.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“No.
For his power to flow to you, you would have to be the arbiter of his death.
You would have to be responsible for his demise.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’ve
been down this road once before, my dear Lillie. I had his life in my hands and
I gave it back to him. Killing is not my
style.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Well,
I think it could be done in such a way that it isn’t really murder. I think if
he is ill and you have the power to intervene and cure him, but you withhold
the intervention or there is some sort of, what do you call it, complication,
the result would be the same.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe it <b>would</b> be a good thing. Not intervening or having an unavoidable
complication is definitely different from a deliberate act of murder. Or, is
it?</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Well,
such speculation makes for good philosophical discussion. However, the last
time I saw your Boss he looked to be in peak health. I really did a great job
on him, even if I do say so myself.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Lillie
didn’t answer right away. She appeared lost in thought.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You
know,” she finally replied, “he did have cancer, cancer of the pancreas. From
what I know of this disease, even with a supposedly curative resection, it is
notorious for recurring. You never know. The Boss could return from his trip
with cancer racing through his body.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Too much talk and not enough sex.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“My
dear, I think that we should let the Boss and his cancer alone. If it is
destined to race through his body, then so be it. But, while wait for cancer to
race through his body, I wouldn’t mind racing through your body instead,” I
remarked as I grabbed her around the waist and pulled her towards me.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
next morning, after Lillie had left I mulled over her proposal<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">You could have such power; you could
do so much good and Lillie would be with you. You could live forever, be a sort
of Surgery God. All the petty politics of the hospital would be meaningless. No
more SCIP, no more battling soulless EMR’s. All your valuable time could be
spent doing what you love best.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I
need to clear my head,” I said out loud.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
jumped in “Black Beauty” and headed out or town.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I’ll cruise some of the country roads</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">About
forty miles outside of the city, the suburbs give way to a jumble of forests
and farmland. Fields filled with corn alternate with cow pastures. The roads
twist and turn and the farther one goes the sparser are the homes. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
opened the sun roof and the throttle and raced up and down hills and around
hairpin turns. I turned my music up as loud as I could stand, allowing Roger
Daltry to serenade the countryside.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“<i>…teenage wasteland, it’s only teenage waste
land…they’re all wasted…”<o:p></o:p></i></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
sang along, letting all thoughts of Satan, surgery, Lori and even Lillie fade
away as I exalted in the warm rays of the sun, the wind and the Who.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Ever since I was a young boy I
played the silver ball…”<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Tommy”
filled my ears as I raced along deserted roads. I was driving over a narrow
bridge when I noticed the smell.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
was smoke, like burning oil and then I saw a black gray cloud wafting up from
the bottom of a ravine. I slammed on the brakes and spun the car around and
drove back to the ravine, stopping at the edge. Down at the bottom I saw smoke
billowing out of a car which was wedged between two trees.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
grabbed the first aid kit from the trunk of my car as well as the Swiss Army
knife I kept in the glove compartment. I felt like a Boy Scout, prepared for
anything. I raced down the grass covered hill to the car, hitting 911 on my
cell phone.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“No
signal.” <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I don’t think I have time to find a
spot with a signal. I hope that car doesn’t explode.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
reached the car and saw there were, or had been two passengers, an older woman
and a young girl. The older woman was obviously gone as she had been nearly
decapitated, but the girl, who looked to be about five was moving in the back
seat, still strapped into a child’s car seat.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Hurry, hurry. My god, look at her
face.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Indeed,
her face was bloody and swollen and I heard gurgling noises as she tried to
breath. I tried to open the door, but it was jammed. All the doors were jammed.
The windshield was smashed and it looked like crawling through from the front
seat was the only way to get to her.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Carefully,
carefully, but with determination I jumped on the hood and began to slide
myself through the open space where the windshield had been, going head first
on my back. My clothes snagged on the shards of glass, which scraped and tore
my skin. As I reached the girl the car suddenly settled and smoke began to pour out from the floor.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Don’t blow now. I’m almost there.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
managed to reach her and began to release her from the car seat. The seat belt
latch was folded under the twisted wreckage. My pocket knife came in handy as I
cut her free.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
made a quick survey of her, trying to discern any potential injuries as I
cradled her in my left arm, doing my best to support her head and neck. She was
still making gurgling noises and I could tell she was moving some air.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Try not to make her injuries worse,
be gentle, but be quick.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">After
an eternity, I had her out and I laid her on the flattest surface I could find,
well away from the smoldering car. I felt for her pulse and was pleased to feel
a strong radial and carotid. Her face was a mass of edematous eyes and cheeks,
her jaw was deformed and there was blood in her mouth and nose. She seemed to
be moving adequate air, but as I was assessing the situation, more blood
started to pour from her mouth and the gurgling stopped. I tried to clear her
airway without success.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Cricothyrotomy. Let’s go Swiss Army
Knife.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
pulled open the pocketknife, did my best to feel the landmarks on her neck and
started to cut. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">My
hand started to shake.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Come on, you can do this. You have to
do this.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">My
hand shook even more. I kept cutting, finally poking the tip of the knife blade
into her windpipe.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Blood
poured out. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
tore open the first aid kit. There was some gauze which I used to wipe away
some of the blood and I stuck the can opener blade on my knife into the airway
and rotated it as I tried to prop open the airway. Blood was still oozing from
the hole.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">There must be something I can use to keep
the hole from closing.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
found some gauze and tape, a bee sting kit, rubber gloves, a flexible splint
and a few other odds and ends.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">That might work.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
took the splint and cut it in two. Then I took some of the adhesive tape and
began to wrap it around the splint to create a tube. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I hope it’s not too big.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">As
I began to put my makeshift endotracheal tube through the surgical airway, my
hand began shaking again, this time so violently that the tube went flying and
my knife which was keeping her airway open became dislodged, falling into the
grass.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Blood
poured into her neck and she stopped breathing.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“NO,
NO, NOOO,” I screamed.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
found the pocket knife and made a futile effort to reestablish her airway, but
blood kept pouring out. I was too slow. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She
was gone. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
felt for a carotid pulse, but there was nothing. The poor girl lay lifeless.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
put my face into my hands and then looked up at the blue sky.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“WHY,
WHY?” I screamed to an invisible god. “Why am I made to suffer?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Hello,
Hello down there. Do you need some help?” an unseen voice called out.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I
did,” I replied weakly. “I did need help, but it’s pointless now.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Two
men came running down the hill.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I
tried to save her. I did my best, but I failed… again,” I mumbled as I walked
away like a Zombie. “I’m sorry. So sorry. I did what I could, I really did.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">They
stared at me as if I was crazy as I slowly walked up the hill.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Wait…”
one of them said, but I just kept on walking. I climbed into my car and sped
away.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I might as well just quit for good.
How can I do any sort of surgery ever again? Maybe Lillie is right. Take the
power, use it for good. That may be my only hope. <o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">But, it’s Satan? Could any human
handle such power; wouldn’t the evil control me? What if I became a monster? <o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">You don’t need to work. You’ve got plenty
of money now.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">But, I do need to work. It’s like
breathing.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
was racing at breakneck speed through the back roads, up and over hills and
through twists and turns. As I raced around one turn I suddenly was staring at
a dump truck moving slowly along the road, heading straight towards me as I
veered into his lane. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">For
a moment I raced straight at him. I heard his horn blaring, but I stepped on
the gas. At the last moment he veered to the right and I turned away. I watched
him through my rearview mirror as he stopped and jumped out of his truck and stared
back at me as I sped away. As soon as he was out of sight I slowed down.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
decision was made. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
called Lillie.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’m
ready,” I said as matter of factly as I could.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Wise
choice. You will be the most famous, respected and beloved surgeon on this
planet,” she answered, although there was something in her tone that I found disconcerting.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Are
you happy with my decision, my dear?” I asked.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Of
course, it is what we both want.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
thought for a moment and then I added, “What about you? Before you told that
your life was bound to Satan’s. If I take his place, will you be OK?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I
will then be bound to you, body and soul.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Not such a bad prospect. But what
about the Boss?<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">As
if she had read my mind, Lillie began espousing her plan.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“The
Boss called today. He is on his way home and he told me he is not feeling well.
He said his stomach was hurting and he had a lot of nausea. He asked to have
his doctor waiting for him. Can you be here by four? He’ll get to the office around
that time.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Sure,
I’m about an hour away and I’ll need to pick up my little black bag.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“We’ve
got plenty of medical supplies here. Just be here by four,” she sounded a
little annoyed.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Certainly,”
I answered and then I hung up.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I’d
almost forgotten about the car accident and the little girl and my failure. The
sorrow and self pity I’d felt only a few minutes earlier gave way to a jumble
of new feelings: excitement, elation, anticipation and hope. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I will be a surgeon again. I will
have the respect I’ve deserved all these years. No more review boards, no more
mindless documentation, no more…<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">My
thoughts vanished as I approached town. I’ll make a quick stop at home first.
It was only half past two. I had plenty of time to clean myself up. I drove
past the elementary school on my way home. The children were in the yard,
playing, running, laughing, doing all the things little children should do. My
thoughts wandered back to another little girl, a girl lying dead, a girl I had
killed.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I’ve killed a helpless little girl
and I almost killed Lori. I’m getting good at this sort of thing. Disposing of
the Boss will be easy. <o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
turned on the TV as I took a shower. There was an old movie playing, “Mr.
Skeffington,”<i> </i>with Claude Rains and
Bette Davis. It was a story about a good, patient man and his vain, cruel wife.
I changed into my black scrubs, had a bite to eat and watched the end of the
movie. Job, the Claude Rains character, is found sitting on a park bench, a
broken man at the hands of Nazi Germany. He is brought to his former home,
where his ex-wife, Fanni, played by Bette Davis, lives. She has become worn and
has lost her once legendary beauty to disease. In a heartwarming scene the two
are reconciled while their former roles are reversed, Fanni will now care for
the broken Job.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Stupid old movie. Time to go.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">As
I started Black Beauty I felt the same sense of exhilaration, along with a
touch of apprehension I usually felt before a big complex surgery. I began to
consider all the possibilities and pitfalls.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Don’t worry about all that. I’m sure
Lillie has taken care of everything. You just have to be there and the deed
will be done. And you’re not really killing him. Just not treating him. It’s
not the same thing.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">As
I drove away I thought about all the times I had put my faith in others. How
many times, as a resident, did I ask an intern or junior resident to draw blood
or follow up on an X-Ray, only to learn later that the task was never done,
leaving me to explain why to my superiors. Or, even, now the multitude of
missed or neglected orders on my patients which may have led to complications
if I hadn’t been so compulsive and checked on every little detail. I guess the
point was that other people are often unreliable and tend to disappoint.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Should I have such confidence in
Lillie? Or is she like all those interns and residents. She seems very
efficient, maybe that’s why I love her so, why I am willing to go along with
this deed. No, it’s more than that. It’s a second chance, a new start for me
and for humanity. A chance to free the world from evil, perhaps forever.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Lillie, my dear Lillie, you have been
wonderful. Now we will take a big step together and take Satan’s power and
together the two of us will bring so much good into this forlorn world.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
pulled up in front of their office building and headed up to the fortieth
floor. The big glass double doors at the entrance opened automatically and
Lillie me ushered me into the inner office. Huge floor to ceiling windows
looked out over the city, filling the room with sunlight.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Let
me get the curtains,” Lillie remarked. She hit a button and the blinds closed
and the lights automatically came on.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">At
one end of the room was the Boss. He was on an exam table, an IV running into
his arm, breathing was labored, he looked yellow again and there was dried
blood around his mouth.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">This all looks very familiar. Didn’t
I just go through this a few weeks ago? I just saw him and he looked completely
recovered, more healthy than me. How could Satan go from vigorous good health
to the brink of death so quickly? What is going on?<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">As
I was thinking The Boss turned his head and vomited, filling a basin with dark
blood. His labored breathing mixed with the monotony of the monitors and an
occasional groan.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“He
certainly is at death’s door. Ironic, isn’t it? Satan, the villain who brought
Death into the world will get a taste of his own horror,” I observed. “But, my
dear Lillie, how is it that his power will be transferred to me. If I just
watch him die, how will I take his place?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Well,”
she explained, “it’s not as easy as all that. If you want to assume The Boss’s
place, you’ve got to be a little proactive.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“What
do you mean, proactive?”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“It
means you must have a hand, even if it’s a miniscule hand, in his demise. He’s
dying anyway, just give him a little push.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">But what about merely withholding
potential lifesaving treatment? That is what she had told me. I don’t like the
rules changing in the middle of the game.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">As
she said these words, the Boss vomited another bucket of blood and his
breathing became even more irregular and raspy.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“If
you want his power you had better hurry. He doesn’t look long for this world.
Just look around you. There is a tray full of anesthetic agents, a table full
of surgical instruments, a variety of endoscopes and lots of other meds.
Surely, you can do something. Perhaps, you are planning to do an endoscopy,
which would require some sedation. Just give him some of the Propofol which is already
drawn up and sitting on that tray. Maybe, you give a bit too much for his
weakened condition and he arrests. You were trying to help him, but he just had
a “complication,” just a miscalculation on your part.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Can power be worth such a price? But,
he’s dying anyway. His death should not be in vain. His evil power could be transformed
into so much that is good.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
walked around him. Lillie shadowed my steps, staying against the curtain, but
exhorting me onward with each step.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Yes,
yes, take the syringe, inject it into his IV. We will have our life together
and the world will be free from “The Boss.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">As
I picked up the syringe a jumble of thoughts filled my head. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I will have my life as a surgeon
back.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Lillie will be with me forever.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Evil will be vanquished.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Go
ahead, free us, free me.” I heard Lillie’s voice in the background.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It’s always her voice.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The Boss has never spoken evil to me.
I’ve never seen him commit a malevolent act.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Then
my thoughts jumped to a totally different subject.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Mr. Skeffington? Job and Fanni? An
odd thing to think about at this time… Job?<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Carlos Anais.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">That
was the most bizarre thing to pop into my head at such a moment. Carlos Anais
had been a patient of mine when I was Chief Resident. He was only thirty, had
been losing weight, had severe abdominal pain with signs of peritonitis and he
was HIV positive. All the consultants on the case agreed he needed surgery
although no one had a clue about the underlying cause. Most thought he had some
sort of malignancy, others considered dead bowel.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">My
preop diagnosis was much different. I
diagnosed intraperitoneal atypical mycobacterium. I even went so far as to
document this unusual conclusion in the chart. Sure enough, that was what I
found. I couldn’t do anything to cure him, but I became a legend. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Why
should I recall a patient from almost thirty years ago, at this moment? One
thing is clear, when Carlos Anais’ name popped into my head, all my muddled
thoughts crystallized. Lillie, the Boss, evil, it all became very clear.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
stared at the white milky fluid in the syringe and stuck the needle into the
Boss’s IV and began to inject it. I heard Lillie take a deep breath. But,
before any of it reached his arm I ripped the IV out, wheeled around and pushed
my darling Lillie as hard as I could. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She
reeled backwards, between the curtains, smashed through the window and
plummeted towards the street below. I ran to the window and looked out just in
time to see two black winged creatures swoop down out of nowhere and catch her.
Then I watched as three black winged monsters flew away. A loud screeching
noise filled my head until they were out of site.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Doctor,”
I heard a raspy voice call. It was the Boss. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
went to his side and held his hand. I started to call 911, but he put his hand
up and pushed my cell phone away.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“How
did you know?” he asked, his voice barely audible. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">How did I know? Good question. Was it
logic which managed to poke its head through my own lust for power? Good
overcoming evil? Divine intervention? A dangerous wager against evil?<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Lucky
guess,” I finally answered.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Please,
doctor, what is your name?” he asked, reaching up and grabbing my scrub top.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Zachary.
Zachary Morse.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You
are a smart doctor, Zachary Morse. You have freed me and saved yourself from a millennium
of torment. Now, please, let me go,” he whispered.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“But
we can save you.’<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You
already have, you already have. Now, it’s my time for rest.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">He
mouthed some inaudible words and gave a faint smile and then he passed away. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
left that place quickly.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
went home and waited, walked the dogs, drove my car and wrote this story. I
expected to hear a knock on my door one day. Perhaps the police, the FBI, a
priest or a black demon, but so far I have been left in peace.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
hospital finally finished its investigation. I was given a slap on the wrist.
The panel agreed that I had called for help appropriately when I realized I
would be unable to complete Lori’s operation. There was some questioning of my
decision to be her surgeon because of our relationship, but technically no
rules were broken. I was to undergo a complete physical exam including
neurological testing and I was to be proctored for my next five surgeries. I
wasn’t concerned. My hands would be steadier than ever.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">After
another week I finally dug up the courage to go to the hospital and visit Lori.
I saw her sitting up in bed, extubated, eating, starting on the first few steps
with Physical Therapy which would lead to complete recovery.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’m
sorry,” I whispered. “I should have saved you.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“From
what I’ve been told, you did,” she answered. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
held her and we didn’t say anything for a while. Finally, after a few minutes
she spoke again.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You
know, while I was so out of it I had the most bizarre dream. I dreamt that
Satan was an evil woman and she was trying to entice you to join her and that
you were tempted and almost did her evil bidding. It was just at the last
moment that you came to your senses and escaped. Isn’t that strange?<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .4in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Yes,
very strange; impossible,” I answered.<o:p></o:p></span></div>
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David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-41206269586088822032015-12-06T13:47:00.001-08:002015-12-06T13:47:47.427-08:00Surgical Dilemma, Part Two<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’ll be about an hour late for my first case,” I
informed the OR desk.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“OK, Doctor,” Eve replied. “There’s nothing behind
you, so that shouldn’t be a problem. I’ll let anesthesia know.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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. <o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Nothing
new under the sun.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The sweet sound of Bach filled my car during the
twenty minute drive to work.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Good Morning, Dr.” the preop nurse greeted me with a
big smile. “Your first patient is in room twelve.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Thank you, nurse. You’re always so efficient,” I
replied smiling back, weakly. <o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Hey, Jeb,” I called out to Dr. Samson, my anesthesiologist
for the day. “Sorry I’m late.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Lori is upstate at her mother’s for a few weeks. I
was working, if you must know.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Really? It wasn’t here.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Long, complicated story. Maybe, I’ll tell you when I
have more time. Anyway, let’s get to work.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Today, looking through Annabelle’s book shelf I discovered
an extraordinary book about surgery. The title is ‘The Amazing Journey….’ <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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?<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I finished my lunch and made quick work of my rounds.
I called the office and arranged for my patients to come in earlier. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">My office manager, Suzy, was waiting for me as I
arrived through the back door.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The regional director for Affiliated Health Care sent
this e-mail.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“This should ease your burden, Dr.” Suzy stated.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Not enough to retire, though.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Maybe you won’t have to work quite so hard.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Perhaps, but I like to work. All I have at home are
the dogs.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You could see them more.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Speaking of patients, all the rooms are full. You should
be out of here by three today.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Good, because I’m really tired.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I thought Lori was away visiting her mother.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I was working last night, Miss Know-it-all. You know,
saving lives, stamping out disease, making the world a safer place for
society.”<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe
the last part isn’t true.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">My cell phone buzzed. I didn’t recognize the number.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Yes, this is the doctor.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Doctor__?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Yes, that’s me.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">What’s
going on? Anabelle and now the local paper? I suppose the President will be
next.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Free
dinner at Leo’s? I guess I do have to eat.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I know. It must be rough being a surgeon. See you at
Leo’s.”<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I arrived at five forty and met Saul at the bar where
he was finishing a double Scotch on the rocks.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Mr. Lewin?” I inquired.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">He stuck out his hand and gave me a limp handshake.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Saul,” he replied. “You are the famous surgeon I’ve
heard so much about?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Surgeon? Yes. Famous? Only in the eyes of my mother.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Annabelle disagrees.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I didn’t answer. The Maîtres d’ ushered us to our
table where a bottle of champagne was waiting.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Dom Perignon? You must want more than an interview.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“The paper gave me free reign and an expense account.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Can we order dinner first? I’ve barely eaten all day.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Sure.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">We each ordered a steak.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Now, tell me, surgeon, what is about surgery that
made you choose it as your specialty?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Has your opinion of surgery changed over the years?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“No. ‘To cut is to cure’ the poet once said. This hasn’t
changed.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“What’s your favorite operation?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Have you ever operated on someone; someone seriously
ill let’s say, who didn’t deserve to live?”<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Does
he know something? How could he?<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I think he saw the perplexed, distressed look on my
face.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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?”<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Coincidence?
Tempted? Tempted is not the same as doing.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Never, I’ve never considered not doing my best for <b><i>my</i></b>
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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You were up all night last night, doing surgery?” He
wondered out loud.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Yup, saving a life.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“What were you doing?”<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Why
would he ask? Does he know? I think he’s fishing.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Sorry, can’t say. HIPAA and all that,” I replied.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I finished my coffee and said my goodbyes, thanking
him for dinner and for the free publicity.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Be sure to mention my book,” I added as I got into my
car.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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:<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Israel and Palestine Reach Historic Accord”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Farther down on the page was another headline
extolling good news:<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Terrorist Cell Arrested”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">And on page three:<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Serial Rapist and Killer Apprehended”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Finally:<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Mother Dog rescues Puppies”<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It was after this, as I freed the tumor from the right
side of the abdomen that I noticed it. <o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It’s
nothing, just lack of sleep.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Never
had a problem like that before, even with lack of sleep. Maybe I’m getting old.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The phone rang bringing the free and clear message
from pathology. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Let’s put Mr. Belson back together,” I announced to
no one in particular. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Is everything OK, doctor?” the tech asked.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She
sees the shaking. I’ll bet everyone can see it.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Fine, just a bit of a reach putting him back
together,” I answered, doing my best to hide my concerns.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I managed to finish the anastomoses and close up Mr.
Belson. As I sat in the dictation room I stared at my hands.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Are
you trying to tell me something? Is it time to put the old scalpel away? </span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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. <o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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 <b><i>was</i></b> a better place.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I was a wreck. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You,” I exclaimed as I wrapped my arms around her, “are
a site for sore eyes.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I gave her a very long kiss.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Your mother is better?” I asked.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Another
gift of gratitude?<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I shook my head.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Everything OK?” she wondered out loud.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I kissed her again.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> “It is now.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I gave her another long, deep kiss, then another and
another.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’m starving,” she said, as she pulled away, “for
dinner. Bed can wait a bit.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Alright, fair maiden. What will it be? Pizza? Sushi?
Something quick would be better.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“This is Dr. Jonas in the ER. We’ve got a Level I
trauma, pedestrian struck by auto.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’ll be right over. I’m just down the hall.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“What happened?” I asked.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“She stable?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Last BP was 90/65, heart rate is 110. She’s awake. I
bet she’ll have something in her belly.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">We went into the trauma room together. <o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">What?
Lori?<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Even through the blood stains and C-collar I
recognized my Lori. I ran to her side.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Lori, can you hear me?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She gave me a weak smile.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Doctor…you’ll take good care of me and we’ll be back
together,” she whispered.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I promise…promise to do everything.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“BP is 70/40,” a nurse shouted.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Do we have blood ready or at least O negative?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Here it is.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Pump it in, call the OR and make sure they have a
room,” I commanded, going into full trauma mode.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“CT says she’s got a lot of blood in her belly,” Dr.
Jonas reported.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“OR is ready.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Let’s go. Make sure we’ve got more blood available.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Get
in, pack everything, stop the bleeding, make sure there aren’t any holes in the
bowel and get out. Quick and easy.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">With the last swipe of the prep I moved to her right
side.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Let’s go,” I commanded.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">A stem to stern incision and some rapid work with the
Bovie brought me into her abdomen where I was greeted by blood.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Laps,” I barked and proceeding to pack every corner
of her belly while suctioning and pulling out blood and clots.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Do
it right. Start in one corner and work around. She’s stable at the moment.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Looks
like the money is on the liver.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Suction.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I couldn’t tell where the blood was coming from. <o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe
behind the duodenum? Vena Cava? Time for some fancy footwork. <o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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. <o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
need to work fast.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I exposed the vena cava below the kidney and
compressed it with a sponge stick.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Hold this and try not to move,” I instructed my
assistant with my “serious” voice.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Pressure is 40,” the anesthesiologist called out.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I noticed my hand starting to shake.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Not
now.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Good
thing you’ve got healthy arteries, Lori.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Pressures better, 70…90,” the voice at the head of
the table reported.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’m running out of hands. Can you get me another
body?” I requested loudly. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’ll try,” the circulator answered.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">And my hand was starting to cramp.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’m here,” Anson, one of the surgical techs declared.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Good, I need some more hands,” I answered.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Are you OK?” Anson asked.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“It’s just because my hand was cramping while I was
compressing the aorta. I should be OK in a minute.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I need a vascular clamp, actually I need three
vascular clamps, two Satinsky’s and a straight one.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Finally, the injury was isolated and ready to be
repaired. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“5-0 Prolene,” I requested.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
doesn’t get much easier than this. Just do it. It’s Lori. She’s depending on
you.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">As the needle moved closer to the vein the violent
tremor began anew.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Nurse, could you call Dr. Ponce, please. Ask him if
he can come and help me out,” I requested quietly.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Lori
is depending on me.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The silence in the OR was almost deafening. I could
almost hear my OR crew’s thoughts.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“He froze.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“He shouldn’t be operating.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“This patient may die because of <b><i>Him.</i></b><i>”<o:p></o:p></i></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“…because
of <b>his incompetence</b>.”<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Dr. William Ponce arrived.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Sure, no problem.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“There’s a hole at the junction of the right renal
vein and IVC. Just needs a few stitches.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Satan.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
guess I <b>used</b> to be a pretty good
surgeon. Mr. Satan looks like he’s made a complete recovery.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Repercussions would have to wait. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">My career was over.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 0in; text-indent: 0in;">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><br />
<!--[if !supportLineBreakNewLine]--><br />
<!--[endif]--><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><br />
<!--[if !supportLineBreakNewLine]--><br />
<!--[endif]--><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><br />
<!--[if !supportLineBreakNewLine]--><br />
<!--[endif]--><i><o:p></o:p></i></span></div>
<div class="MsoNormal">
<br /></div>
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David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-18025284034674689382015-11-11T17:03:00.000-08:002015-11-11T17:03:03.711-08:00Surgical Dilemma Part 1<div class="MsoNormal" style="text-align: left;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Come on, quickly, quickly, we think he’s dying,” a
female voice called, the sense of urgency was unmistakable.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I tried to shake the sleep from my head as I pulled on
some scrubs and followed this stranger.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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?</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Where are we going?” I asked, naively.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Why
do I feel like I’m in some sort of bad movie?</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Could you tell me who <b><i>he </i></b>is?” I wondered out
loud.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
Boss? Who’s the boss? The President? The Pope? Springsteen?<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">We pulled into the black garage. A faint light
illuminated an elevator door which is where we stopped. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Get out here,” she requested/commanded.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The elevator doors opened and I stepped in, alone.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Must
have been forty or fifty floors judging by the time it took to stop.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
guess my patient will be on the other side of those doors. This is all too
James Bondish.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">This
does not look good for “the boss.”</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">A nurse came into the room through a different door as
I approached the bed.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Hello, Dr…” <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I looked up at the nurse, “Excuse me, do you know ‘the
boss’s name?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Satan,” she answered with a smile on her face. “I’m
sure you can see that he is very ill.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“That’s for sure, Ms…”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Wait,
did I hear her right?<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You did say Satan, as in Lucipher, the Devil, Father
of all Lies?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Yes, you heard correctly.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Why should the Devil need a surgeon? Isn’t he
immortal, a fallen angel?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Sounds
like someone trying to convince themselves.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“If I refuse to be ‘Satan’s’ surgeon? What happens? Is
it one of those if he dies, you die scenarios?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You may be right about that. He doesn’t look too
good. Do you have any monitors here?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Of course. I’ll hook him up while you look through
his chart. These are his last vital signs.”<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">110/60,
110, 28, 37.9. Normal Saline hanging. OK, Satan, let’s see what you’ve been up
to.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’m sorry,” she said, “start with this one.
Everything from the beginning is translated into English.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She pulled out a blue chart from the middle of the
stack and handed it to me.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">‘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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’m working on that,” she called out, letting me know
that even my whispered unintelligible comments did not go unnoticed.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Better
be very careful. <o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I started at the beginning:<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">May 23, 2300 BC: URI, resolved spontaneously<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">April 11, 1302 BC: lacerated left arm from fall from
chariot, healed over 4 weeks by secondary intention.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">June 6, 998 BC: suffered food poisoning while in the
house of Ahab, severe diarrhea for 4 days, recovered completely.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
guess our modern world does not agree with Mr. Satan.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I opened up the full chart and perused the most recent
notes.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“UGI bleeding secondary to esophageal varices.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Drinks a quart of whiskey a day.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Previous stent in LAD and right coronary.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Poorly controlled diabetes.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The notes were all signed with an “X.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">There was another chart with the results of his most
recent lab, each test was done within the last two days.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">WBC 27.4<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">H/H 9.2/27.7<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Na+ 135<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">K+ 4.4<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Cl- 109<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">HCO3- 19<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">T. Bili 7.6<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">ALT 205<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">AST 320<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Alk. Phos 887<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">BUN 38<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Cr 2.4<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">CT Abdomen and Pelvis: Bilateral Pleural Effusions,
Cardiomegaly, Dilated Bile Ducts, Three cm mass in the head of the pancreas or
distal bile duct. <o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Let
me look at these images<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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?<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Then the indignation started to rise. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I don’t know, I just don’t know. Oh, by the way, who
is this Dr. X. who has been signing these notes?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“So, let me see if I I have the complete picture.
Satan,<b><i> the </i></b>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?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“And his minions, his demons?” I wondered out loud.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I only know what will happen to me.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I need some time to think this through. Give me a few
minutes.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Very well,” she answered, “but I’m going to try to be
positive and begin to get him ready for surgery.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I sat on the lone chair and closed my eyes.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">On
the other hand, suppose I do the surgery, cure him of his cancer. Could <b>I</b></span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> <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?<o:p></o:p></i></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Life
and death decisions are one thing, but life and death for all of mankind?”<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I opened the door and went into the next room. I was
greeted by the steady beeps of the monitors.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Ok,
I’ll do the surgery.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Let’s go ahead and put him to sleep,” I ordered. “Did
you happen to steal an Anesthesiologist?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Relax?
I don’t think so. <o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“We’re ready, doctor,” Miss Vargus reported
interrupting all the worries which were brewing inside my head.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I washed my hands, stepped into my gown, donned my
size 8 white gloves and we were off. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I looked at Satan’s exposed abdomen and the OR lights
followed my eyes. <o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Amazing
lights.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Scalpel,” I began.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The knife was slapped into my hand and I started with
my usual chevron incision. <o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Lots
of big veins. I hope Satan’s not cirrhotic.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">You’re
going to make this easy for me, Satan?<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Is everything OK, doctor?” I heard Vargus ask.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Yes,” I mumbled and the image faded away.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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. <o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Is
it murder to kill a murderer?<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> I kept on
working, gently retracting and teasing the common bile duct, separating it from
the portal vein.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Hold the retractor this way, Mephistopheles,” I said
to one of my silent assistants, moving his hand to the right. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I glanced across the table and, I swear, there was the
faint red glow of anger filling my assistant’s eyes.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> 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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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…<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Just do it. A common saying. I don’t think Nike meant
commit murder.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
can’t…can’t do it, not that.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Suction,” I called out and one of the assistants
thrust the suction device into the wound.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">What
a fool you are, that could have been his end and you didn’t even plan it.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“No, no,” I spoke loudly.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“It’s Ok, Dr., you’ll get it under control,” Vargus
reassured.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I knew that I would. I’d faced far worse situations
without turning a hair more times than I cared to remember.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Should
be smooth sailing from here.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Satan,
</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">you<i> don’t deserve to live. </i><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“OK, let’s put Mr. Satan back together,” I announced
to my silent assistants. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
don’t deserve to live.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You do fine work, doctor,” Ms. Vargus declared as I
ripped off my gown. “You deserve to be rewarded.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She gazed at me with a look I could not comprehend.
Fear? Envy? Longing? By rote I sat down
to write orders.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“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.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Don’t worry. He will recover completely. I promise.”<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Somehow,
she knew that he was cured. Sadly, so did I.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">A
horrible nightmare?<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">God,
please, make me clean.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">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.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The nightmare was far from over.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><i>Look for Part 2 in a few weeks. Comments about what you would do in this situation are welcome.</i></span></div>
<div class="MsoNormal">
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<div class="MsoNormal">
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<div class="MsoNormal" style="margin-left: 0in; text-indent: 0in;">
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<br />David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-11278395236096664462015-10-18T14:09:00.002-07:002015-10-18T14:49:03.376-07:009 1/2 Weeks<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I met Alice almost by accident. Sunday morning rounds
were nearly completed when I passed Dr. T. in the hallway. We exchanged
pleasantries and then walked on in opposite directions. But, seemingly as an
afterthought, he called out.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“”Do you think you can go by and see a patient for me?
Her name is Alice. She’s in room 402. She’s in the hospital with constipation
and she’s pretty distended. I plan a colonoscopy tomorrow, but, maybe, just
give her a quick look. She had a CT that just showed constipation.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Sure,” I replied, “I’m going in that direction
anyway.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Alice was petite, weighing in at 98 pounds and she
certainly was distended, almost like she was about to deliver twins. She was
46, had always had “bowel trouble,” had previous back surgery and was on
chronic pain medication, taking Percocet several times a day. She had not had
previous abdominal surgery.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Does your abdomen hurt?” I began.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“All over, but the Dilaudid helps,” she replied.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“When did the pain start?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“About three weeks ago, but it got worse three days
ago.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“When’s the last time you had a bowel movement?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Nine weeks before I came into the hospital.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I had to stop for a moment to completely absorb this
statement.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
think this is a record.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Did you say nine weeks?” I asked again.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Yes, nine weeks.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“…and you’ve been here three days, so it’s been nine
and half weeks since you had a BM? Is that unusual for you?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Normally I go every three or four days. I did start
to panic after a week, but I didn’t know what to do.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Are you able to pass gas?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’m not sure.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Let me check your abdomen.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She was extremely distended and had diffuse
tenderness, and some signs of peritonitis, particularly tenderness to light
percussion on the right side of her abdomen.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’m going to look at your CAT Scan and then I’ll be
back.”<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">So
much for getting rounds done at a reasonable time.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The CT Scan done the day before revealed just what one
would expect in patient who had been constipated for nine and half weeks. The colon
was dilated, filled with stool, but not much air. The cecum, the first part
measured ten centimeters, approaching the diameter where blowout becomes a
concern. The dilated colon stopped in the mid sigmoid colon, which is just
above the rectum. There was no definite tumor or mass, but there was a definite
transition point from dilated to collapsed colon.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I checked her labs next. Her white Blood Cell Count
had been slightly elevated at 12,000 the day before, but today it had jumped up
to 35,000. Her bicarbonate level was 14, which is low, normal being around 25.
Low Bicarbonate suggests metabolic acidosis, a sign of severe metabolic
derangement and sepsis.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Taking everything together there was no question. She
needed surgery. She either had perforated her colon or she had dead or dying
colon. Either way it was a life threatening surgical emergency.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Of course, Sunday is not the best day to get anything
done quickly. There were a series of Orthopedic cases scheduled already.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I need to do this lady soon,” I explained to the
crew. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“It looks like you’re in luck. Dr. R. just cancelled
his last two cases and we are finishing up with him now,” the OR nurse
reported.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Good.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I explained my findings and concerns to Alice and her
family, put her orders in the computer and waited for the OR crew.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe
just a colostomy will suffice. But, it would be better to eliminate the cause
of the obstruction. Quick and simple will be best for her.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">After about 25 minutes Alice was wheeled into OR room
ten and was asleep a few minutes later.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">A midline incision through the taut abdominal wall
brought me into her abdomen which was filled with a few hundred cc’s of
slightly cloudy yellowish fluid. I could see that the sigmoid colon was
massively dilated, but it was not gangrenous. There was a faint, pungent odor.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Looks
like I should be able to remove the offending portion of colon.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I could see where the colon transitioned to normal
caliber just above the pelvis. I began to mobilize the colon by dividing the peritoneal
attachments that tethered the sigmoid and left colon.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Feels like there’s a hard mass in the colon causing the
obstruction,” I observed out loud to no one in particular, my assistant nodding
her head,<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> I should be able to get this colon free and
then…<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Before I could finish this thought the dam busted and
I was suddenly up to my elbows in thick, liquid stool.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Shit…” Literally.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Suction, lap, more laps, more suction.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The suction became plugged with stool. I squeezed the
colon closed with my hand and it fell apart. Like The Blob from the 1950’s or
the river of slime from “Ghostbusters” liquid stool took over.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I need an intestinal clamp, something atraumatic,” I
said loudly.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The circulator scurried out of the room and came back
with the GI instruments. In the meantime I had managed to isolate the source,
rather the sources of the river of stool and began to get at least a semblance
of control.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 0in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> <i>The evil culprit
rears its ugly head.<o:p></o:p></i></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“There’s a big rock of poop causing the obstruction,”
I noted.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Indeed, this “fecaloma” had completely blocked the
sigmoid colon and eroded into the wall of the bowel, setting a trap for me as I
mobilized the colon. As soon as the colon was free it exploded, releasing its
noxious contents. The resultant inundation left poop everywhere, on every loop
of bowel and filled the pelvis.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">With the proper intestinal clamp in hand I stemmed the
flow and went on with the resection. I had to make two passes with the GIA to
divided the dilated bowel while there was no difficulty dividing the distal
colon, stapling it closed with the RL60 stapler.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Home
free.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I finished resecting the sigmoid colon and examined it
on a separate table. <o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">This
colon is as strong as soggy Kleenex.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Uh, Dr. Gelber, I think there’s a problem here.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“What…?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Liquid stool was filling up the abdomen again.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I hurried back to the cesspool which was Alice’s open
belly and valiantly struggled to stem the flow again. The staples had not held
the friable colon together. Once again, we went to work, sponging and
suctioning until I could see enough to mobilize the colon away from its usual
position on the left side of the abdomen, find the hole and carefully put a
clamp across it. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">This time it held, at least enough to allow me to get
my bearings and assess the situation in a calmer, more orderly manner. I made a
closer inspection of the remaining bowel.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The right side of the colon didn’t look very good
either. Muscle fibers in the cecum were split under the tension caused by
massive dilation, the ascending colon had patches of frank gangrene as did the
splenic flexure.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
all needs to come out. </span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Back to work. I began by dividing the attachments to
the cecum and was then able to liberate the hepatic flexure with minimal fuss
and the remainder of the colon followed until everything was free. I zipped
through the mesentery with the Ligasure and before long the colon was resting
in a large basin on the back table. At this point we all changed gowns and
gloves and tried to put banish the pungent odor from our nostrils. Even with
benzoin (a fragrant compound often used in surgery) on our masks and repeated
washing of hands I knew that the fine aroma of stool and dead bowel would
linger with me for the rest of the day.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">This
nasty beast has been far too much trouble. Time to finish this case.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">We spent the next twenty minutes washing, washing and
more washing. Liter upon liter of warm saline was poured, sprayed, percolated
and pumped into every nook and cranny of her abdomen. We squirted irrigation
fluid into the pelvis, above the liver, around the spleen and between every
loop of bowel until the fluid came out as clean as it went in. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Finally, I brought the end of the small bowel out as
an ileostomy, took one more look around her belly and closed her up. Ensconced
safely in the ICU, I washed my hands one more time, wrote orders, dictated the
op note and, last of all, told her family the sordid tale of her surgery.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I called Alice’s Attending physician and consulted one
of the Pulmonary docs, checked on Alice one more time and finally left the
hospital for the day.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Alice was kept on the ventilator, she was very slow to
wake up from anesthesia and her blood pressure hovered in the 80’s;
occasionally dipping into the 70’s. A massive volume of IV fluid and support with
Levophed and Vasopressin were necessary to maintain an acceptable blood
pressure. (These two medications help maintain vascular tone, which helps
maintain blood pressure in patients with septic shock). Her kidneys started to
shut down, but timely adjustment of her fluids and medications by a Renal
consultant turned this around.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The following day she looked a little better, more
awake, good urine output, but still requiring pressor support with Levophed and
Vasopressin. She continued to smolder along over the next 48 hours, neither
improving nor deteriorating. I became a little concerned about her abdomen at
this time as it became more distended and the ileostomy stoma looked dark
purple instead of pink. Her lactic acid level rose to a very high 14, a sign of
worsening acidosis, which indicated seriously poor perfusion of something and
worsening sepsis. Although she maintained adequate blood pressure and kidney
function, it became clear that something was amiss or amuck or afoul.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Alice was taken back to surgery. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The previous wound was opened and a couple of liters
of clear fluid was drained. <o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">That
explains the abdominal distention.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">In the lower abdomen there was some cloudy, foul
smelling fluid. As I gently freed up the small bowel and delivered it out of
the abdomen I discovered the new source of Alice’s woes. The distal small bowel
was dead, not completely, but patches had frank gangrene. I resected about 25
centimeters of terminal ileum and redid her ileostomy. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She also had a portion of abdominal wall which was
dying and this also was excised. I put her back together as well as I could and
delivered her to the ICU and hoped for the best.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The next twenty four hours brought hope as she
required less support with the pressors. However, she didn’t wake up.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The following day came with new events which proved to
be too much. She began to have cardiac arrhythmias, frequent Premature
Ventricular Contractions (PVC’s) and runs of, Atrial flutter and Ventricular
Tachycardia. The Cardiology consultant added his words of wisdom to the already
exhaustive list of consultants.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Acute MI,” he said with a solemn expression on his
face. “Ejection fraction is only 30%,” he said shaking his head.<i> <o:p></o:p></i></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She’s
not going to make it.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Alice continued along for a couple of more days, but
she didn’t wake up, her kidney function gradually declined and her family
wisely withdrew support, allowing her to pass away.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I wish I could report that timely surgery had rescued
Alice. I don’t know how many similar patients I’ve taken care of, how many
times I’ve told families “We’ve eliminated the source of infection; the
perforation, the blockage, the gangrene, the abscess; now it’s time to heal.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Very often it’s this healing phase which proves to be
too much. Organ systems which have suffered the supreme shock of serious
systemic infection are unable to recover and gradually shut down. The initial
sepsis leads to what is called multi organ system dysfunction which progresses
to multi organ failure which often leads to death.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">After I finish operations such as Alice’s I’ve learned
not to say: “Alice (or Andy or Mabel or anyone) will be better now.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I’ve learned that the human body often does not suffer
lightly intrusions by combinations of bile, blood, GI contents or urine mixed
with microorganisms which thrive in such an environment. The body does its best
to fight such invasions and may be successful. But, sometimes as the battle is
fought and the war looks like it will be won, the body dies. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">And, nine and a half week’s worth of poop is more than
most of us could handle.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: 0in; text-indent: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-left: 0in; text-indent: 0in;">
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<div class="MsoNormal" style="margin-left: 0in; text-indent: 0in;">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<br />
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David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-31218641786682041522015-10-13T16:43:00.002-07:002015-10-13T16:43:39.539-07:00Office<div class="MsoNormal" style="text-align: justify;">
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I have, on occasion, described the perfect surgical
practice as one where one operates every day, performing a wide variety of
cases, while never having any patients in the hospital. Perhaps this fantasy is
a bit facetious. Boiled down it means that the surgeon gets to perform the most
interesting part of surgery, that is the actual operation (unless it’s a vein
stripping) while never having to deal with the more mundane and frustrating
aspects of the surgical practice, such as dealing with a draining wound or
impatiently waiting for the post op ileus to resolve.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">There is one aspect of the surgical practice, even a
perfect one, which is absolutely necessary: the office.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">In the office new patients are seen for the first time,
evaluated, examined, treatment options explained and discussed and decisions
made. Patients recovering from surgery come to have their wounds checked and
concerns addressed:<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“When can I go back to work?”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“When can I drive?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“What can I or can I not eat?”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“When can I start having sex?”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Will this lump go away?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Is it supposed to be numb?”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Do I have cancer?”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Each question is patiently answered, worries and fears
are laid to rest, as the patients make their way down the path towards
recovery.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Most clinic days are a predictable mix of patients who
suffer from hernias, gallbladder disease, lumps, bumps and pockets of pus, with
an intermittent spattering of thyroid conditions, gastrointestinal masses,
hyperparathyroidism and other less common ailments. <o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">There was a day however when my office patient was
filled with a stream of colorful patients. I should have known something was up
when I saw the name of the first patient:<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Hazy Racy Autumn.<o:p></o:p></span></div>
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<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Unusual
name…swollen groin…here I come, Hazy.<o:p></o:p></span></i></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I knocked on the exam room door and went in.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Ms. Autumn? I’m Dr. Gelber. What brings you in here
today?” I began. <o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I’m not sure how to describe Hazy Racy Autumn. She was
tall, taller than me and her height was accentuated by a tall furry hat perched
upon long blonde hair. She looked to be the forty years she had reported on her
history form. She had a long silken blue and pink housecoat on and fuzzy Winnie
the Pooh house slippers on her feet.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Racy, please,” she replied as I shook her hand.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Ok, but what brings you in here?”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Dr. N. said it was my nose; my <b><i>limp</i></b> nose.”<o:p></o:p></span></div>
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<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Her
nose looks OK to me. Besides, I’m not much of an ENT doctor. Limp nose, swollen
groin…lymph nodes.<o:p></o:p></span></i></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You mean your lymph nodes, I think,” I explained.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“That’s right. Lymph nodes. Under my arm and in my
groin. There swollen according to Dr. N.”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Is that why you went to see him?”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Three months ago. He gave me antibiotics and then
more antibiotics, but the swelling is still there.”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">We went through the rest of her unremarkable medical
history and then it came time for me to examine her. I’d already noticed that
her submaxillary glands looked enlarged, giving he a little bit of a chipmunk
look.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Put this on so I can examine you,” I requested,
handing her one of our cheap paper gowns.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Oh, I don’t need that,” she decided as she jumped up
on the exam table and opened her housecoat, which revealed Hazy Racy Autumn and
nothing else. <o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She had neatly trimmed her pubic hair into a blonde
replication of Adolph Hitler’s mustache, the remainder was clean and smooth.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I saw Miss Autumn in the early 1990’s, a time when the
current custom of clean shaven pubic areas was not in vogue. The only women who
regularly shaved “down there” were strippers and hookers. Perhaps I was
presumptuous to assume that Ms. Autumn was in one of these lines of work. My
inquiries as to what she did for a living were answered by a vague, “I work
from home” response.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I proceeded with my exam, noting multiple enlarged
nodes in each groin as well as each axilla, all 2-3 centimeters in size. <o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I think we should take out one of these lymph nodes.
That’s what Dr. N. wants me to do and I agree with him,” I explained. <o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Is it something bad, Doctor?” <o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Well, I worry that it could be lymphoma, a cancer of
the lymph nodes, but there are other less serious possibilities. The simplest
thing would be to biopsy one of the groin nodes. Do you want to have that
done?” I asked.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Yes, yes, of course,” she replied with a shrug.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I finished my exam and explained the procedure and Hazy
Racy Autumn was scheduled for a lymph node excision two days hence.<o:p></o:p></span></div>
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<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">A
fine start to the afternoon. What’s next? J.F. Romanov, lump on foot and
buttock.<o:p></o:p></span></i></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I picked up the chart, knocked and went into the next
exam room.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Ms Romanov?” I asked, “I’m Dr. Gelber, what can I do
for you today?”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Hello, Doctor,” she answered with a bit of an accent,
holding out her hand. “I am glad to meet you.”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She was stocky, didn’t wear any makeup, and had dark
brown hair with wisps of gray which was tied back in a ponytail. <o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I have a lump on my, what do you call it, butt and
one on my foot. They do not pain.”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> “How long have they been
there?”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“About two months.”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Painful?”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“No.”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The rest of her history was unremarkable.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Ok, put this gown on and I’ll be back in a minute to
examine you.”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I left her alone and sat at my desk and wrote out her
history while she changed. When I’d finished I knocked on the exam room door
and went in, with my Medical assistant, as always, in tow.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Ms. Romanov sat on the exam table, completely naked.
My assistant handed her one of our paper gowns, which my patient loosely placed
across her waist.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Where are the lumps which you feel?”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You Americans are always so ‘funny’ about nakedness,”
she observed. “Let me show you what I can do.” <o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She shifted her legs up and down before deftly bringing each leg up and placed
it behind her head as the paper gown floated to the floor; a remarkable demonstration
of her flexibility.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You must have been in the ballet to be so flexible,”
I commented, doing my best to act nonchalantly.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Ukrainian circus,” she answered. “But, you see the
lump good, no?”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">As she said those words I looked at her right buttock
and, sure enough, her exhibition did demonstrate the outline of a mass in the
right buttock, about 6 cm in diameter, mobile, discreet, almost certainly a
lipoma.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“And, you see my foot, the left one?” she added.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I palpated the left foot and felt another mass on the
lateral aspect, about 3 cm in diameter, likely a fibroma.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Anything else?” I wondered out loud, referring to the
physical findings. Ms. Romanov, however, interpreted these words differently.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She pulled her legs from behind her head and jumped on
the floor and executed a handstand and began moving her legs back and forth in
a scissors-like manner.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’m sorry, Ms. Romanov, I meant, do you have any
other lumps that you are concerned about?”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She went back to sitting on the exam table and answered
in the negative. <o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She related that she wanted to have the lumps removed
and we set a date for her surgery. I left her to get dressed and went on to the
next room.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Next was Karen Smythe, 58, breast cancer. She came
with a mammogram showing a suspicious mass in her right breast and biopsy which
revealed infiltrating duct cell carcinoma, the most common type of breast
cancer. The mass appeared to be about 2.5 centimeters on the mammogram and
there was an enlarged lymph node, also apparent on the mammogram.<o:p></o:p></span></div>
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<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Not
good..</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Good morning, Ms. Smythe, I’m Dr. Gelber. What brings
you in here today?”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Mrs. Smythe, my husband is Malcolm Smythe. He’s on
City Council. Dr. Z sent me. She said there’s a lump in my breast,” she
answered, her voice quiet, but steady.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“She’s right, there is a lump and I see they did a
biopsy. Did Dr. Z tell you the results?”<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“No, she just told me to come here.”<o:p></o:p></span></div>
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<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Great,
I get to tell this poor lady, whom I’ve just met for the first time, that she
has breast cancer. Here goes.<o:p></o:p></span></i></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Well, Mrs. Smythe, I’ve looked through all the
reports and the biopsy show that the lump in your breast is cancer.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“It is?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’m afraid yes, it is.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Her calm quiet demeanor started to change as tears
welled up in her eyes. She did her best to compose herself as I handed her a
Kleenex.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Am I going to die, can it be treated?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“It certainly can be treated,” I replied, “there are
far more women living and walking around with breast cancer than die from it. Let
me ask you a few questions.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I took some more history and then left the room while
she changed into an exam gown.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">My heart sank a little when I looked at her breast. There
was some retraction of the skin and dimpling over the area of the tumor. The mass
was about three centimeters and there was a hard, but mobile mass in the right
axilla. <o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Stage
III at least. She’ll need chemo before any surgery.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Mrs. Smythe, I think it might be best to have you see
one of the cancer doctors, an Oncologist, before we think about doing surgery.
Let me call one that’s on your insurance. I’ll be back in a few minutes.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I called Dr. S and arranged for her to be seen that
afternoon. We sent Mrs. Smythe away with some literature on breast cancer, instructions
to call with any questions or concerns, and a box of tissues.<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Something
isn’t right when a patient has to first hear that he or she has cancer,
particularly breast cancer, from a complete stranger, even if that stranger is
a doctor.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I zipped through the next five patients who were all
post op from hernia or gallbladder surgery.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Eating Ok?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Yes”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Any fever?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“No”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Bowels working?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Yes”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I reached my last patient, Billie Jean Muller, 59,
abdominal pain.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Good morning, Ms. Muller, I’m Dr. Gelber. What brings
you in here today?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I’m not very creative with my introductions.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Dr. M sent me. I’ve been having pain in my abdomen
for a while.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“How long is a ‘while’?” <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Ever since my hysterectomy.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“And, when was that?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I wrote it down on the paper.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">‘I know, but I like to hear what you have to say. I
find it helpful when trying to figure out what’s wrong; helps me do the right
thing or order the right tests.”<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">This
could take a while.<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Tests? I’ve already had every test. I’ve had CAT
Scans, Ultrasounds, EGD, colonoscopy, HIDA Scan, and MRI’s. My gallbladder is
gone, along with my uterus.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I glanced at her history form.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Your hysterectomy was eight years ago. Did the pain
start immediately afterwards? Or a few weeks or months later.”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I think it was immediately, or, maybe a month or two
later. Then again, maybe I had the pain before that surgery.”<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
need a different approach.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Has the pain become worse recently? Why did you
decide to come today?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Dr. M. told me you could help me. I guess he’s tired
of seeing me.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Where is the pain the worst? Upper abdomen, around
your belly button or lower down?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Lower down, I guess. It’s really bad when have to go
to the bathroom. I have to push on the left side of my old hysterectomy scar or
else it doubles me over.”<o:p></o:p></span></div>
<div class="MsoNormal">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Really?
Could it be something so simple?<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Let me have you put this gown on so I can examine you,
Ms. Muller.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I gave her a few minutes to change.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Let me check you standing up first. Can you cough?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">She gave a weak cough.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“A bit harder, if you can?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Sure enough, there was a definite bulge along with the
typical findings of a hernia. I finished my exam, not finding any other
abnormality.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I think you have a hernia, that is, I’m sure you have
a hernia at the end of you hysterectomy wound. You will definitely benefit from
having it fixed.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I explained the procedure and surgery was scheduled.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Hazy Racy Autumn had an inguinal node excised which
was benign, a reactive node. The enlarged nodes eventually were determined to
be caused by Epstein Barr Virus, a benign condition. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">J. F. Romanov had two lipomas removed. I did not get
any more demonstrations of acrobatic ability.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Karen Smythe was treated with neoadjuvant chemotherapy
which shrank her tumor to almost nothing. She underwent a lumpectomy and
axillary node dissection months later and is still with us today.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Billie Jean Muller had an uneventful repair of her Spigelian
Hernia. She did feel better, but still complained of some pain. She saw a Pain
Management specialist who helped her get the pain under control.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">All in an afternoon’s work.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> <o:p></o:p></span></div>
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David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-14748966433638384192015-10-01T15:53:00.001-07:002015-10-01T15:53:14.804-07:00Battle of the Bowels<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
was Friday afternoon and I was on call for the weekend. Dr. A. from the ER was
on the other end of the phone.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I really don’t feel like working.”<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I’ve
got a good case for you,” she began, “Mickey M., forty five, no medical
problems has had abdominal pain for four days and CT shows a large amount of
free intraperitoneal air.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Is
he stable?” I asked.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Vital
signs are normal, no fever, white count is eighteen thousand, but…”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">There’s
always a but.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“…he
weighs four hundred and ten pounds.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Okay,”
I sighed, “I’ll be there to see him shortly.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">A good case?<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
called the OR and scheduled him for surgery and then walked across the street
to see Mickey.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">At least he had the courtesy to come
in at 1:30 in the afternoon instead of midnight.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Mickey
was large in every sense of the word. He was six foot three, his belly was almost
as tall as he lay on the ER stretcher, his face was flushed and he was a little
sweaty and a more than a little short of breath. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">His
numbers didn’t look that bad: heart rate 90, Blood pressure 145/85,
respirations 24, oxygen saturation 97% on room air, temperature normal. He had
never had previous surgery, took no medications. He winced when I tapped his
abdomen. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Besides
the elevated white blood count he was anemic with a hemoglobin of 9.2.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
CT Scan of his abdomen revealed inflammation around the sigmoid colon with free
fluid and air.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Perforated
colon,” I explained to Mickey, “which will need surgery today. Most likely the
cause is diverticulitis, but it could also be a tumor. We’ll probably need to
do a temporary colostomy also.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Whatever
you need to do, Dr. Gelber, just make the pain better,” he answered.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Funny thing about peritonitis; nobody
that truly has generalized peritonitis ever says “I don’t think I want any
surgery.” </span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Mickey
was wheeled into OR ten about an hour later. A generous midline incision was
made and, upon entering the peritoneal cavity, the surgical team was greeted by
the foul odor of stool and pus which began to well up into the wound.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Ah, the fine smell of festering
stool. A fine way to start my weekend.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Suction,
cultures, more suction,” I called out as what seemed to be gallons of fetid,
infected fluid were evacuated from his abdomen. There were thin adhesions
between the loops of dilated small bowel which were broken with light finger
dissection. This small bowel kept trying
to insinuate itself between me and the source of Mickey’s woes. The
inflammation led me deeper and deeper into the lower abdomen and upper pelvis
until the culprit was isolated: a perforation in the colon at the rectosigmoid
junction.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
small bowel was packed out of the way as I prepared to attack the evil villain
who had fouled poor Mickey. The attachments of the left colon were divided to
help me approach the area of perforation. As I carefully dissected, the small
bowel decided it should try to help and escaped the barrier of lap pads which
vainly tried to contain them out of my way. I packed the small bowel out of the
way again, this time using a wet towel instead of mere lap pads. I next did my
best to identify the ureter and I was pretty sure I saw it as I gingerly
searched beneath inflamed layers of fat and fluid.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">My
hands, then forearms, elbows and almost my shoulders disappeared into the
depths of Mickey’s abdomen as I did my best to dissect below the area of
perforation.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe I should have someone tie a
rope around my waist so I don’t get lost in this pelvis.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“There’s
a mass here,” I announced to no one in particular as I managed to bring the
diseased segment of bowel out of the pelvis.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">At
this point the resection proceeded quickly. The proximal colon was divided with
a stapler, I managed to get a stapler below the area of perforation and the
bowel was divided and stapled closed. The mesentery, which contains the blood
vessels, was divided with the usual clamp, clamp, cut and tie of most bowel
resections and the rectosigmoid colon was removed, thrown on the back table to
be examined later.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
checked Mickey’s abdomen for bleeding, looked at the ureter again and then
washed out his abdomen with bucket after bucket of warm saline solution. Once I
was satisfied that Mickey was clean I examine the resected specimen.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
was about twenty centimeters long. About five centimeters from the distal end
there was a hole about one centimeter in diameter. There was a hard mass just
distal to this hole. I opened up the bowel and saw the tumor, ugly, ulcerated,
almost filling the lumen.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Not
good for Mickey,” I concluded. “Maybe all the stool in the belly killed any
cancer cells that may have escaped.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Time to get on with the surgery.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Three
O Prolene,” I requested. The blue Prolene sutures are used to tag the end of
the rectum, making it easier to find should I came back in the future to
reverse the colostomy Mickey was about to receive.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">A
colostomy is where the colon is brought out to the skin surface. Stool then passes
into a bag, rather than its normal passage through the rectum and into the
toilet. The bag is necessary because there is no sphincter muscle to control
when and where the stool will pass.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Mickey
stayed on a ventilator overnight. His recovery was remarkably uncomplicated,
considering how sick he should have been, He left the hospital nine days after
his surgery.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">One
week later he rolled into my office, smiling, feeling quite well. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“I
feel great, Dr. G,” he reported, “no pain, everything’s working.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“That’s
great, Mickey. You look good,” I answered as I took out his staples, perused
his colostomy stoma, and palpated his rotund belly.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“When
can I get rid of this bag?” he asked.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Well,
you need to heal a bit more and I think you’ll need chemotherapy. The pathology
report says there was cancer in two of your lymph nodes and the cancer was
perforated. We’ll get you an appointment with Dr. H to get his opinion about
chemotherapy. After you’re done with chemo, and assuming everything else is OK,
we can schedule surgery to reverse the colostomy. I’ll see you again in about a
month.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">And
I sent him on his way.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Should be about six months until I
have to tackle that belly again.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Wrong.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
was about 5 weeks later that Mickey’s wife called my office and reported that
Mickey was bleeding from his colostomy, mostly dark blood, but sometimes bright
red. As an afterthought she added that he was having intermittent drainage from
the midline wound through a tiny, pinhole opening.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Bring
him in,” I responded.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">An
hour later the massive form of Mickey along with his diminutive wife graced
exam room three.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“So,
tell me what the problem is, Mickey,” I began.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Just
take a look,” he answered and he pulled up his shirt. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">His
colostomy bag was full of thin dark, bloody fluid. The skin was retracted,
although he had done a good job of keeping his appliance in place. Adjacent to
the colostomy his midline wound had a gauze dressing which was stained with
yellow brown fluid.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“You’re
right, you are definitely bleeding. When did this start?” I asked.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Two
days ago. I’m not having any pain, Oh, and the colostomy doesn’t stick out any
more. It’s been quite a chore getting the bag to stay.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Well,
I think you need to be back in the hospital; I’ll get the GI doc to check out
your colon to figure out why you’re bleeding.”<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Please be something simple, I’m not
ready to attack Mickey and his bowels so soon.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">As
he stood up to leave I immediately figured out the problem. Mickey’s big belly
hung down about eight inches below his belt line. Following his belly was his
colostomy stoma, except his poor colon was tethered by its blood supply,
causing it to pull on the skin. The stoma retracted under the skin while the
blood vessels were stretched.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
final result was a portion of colon which was both congested and ischemic
leading to the dark bloody drainage. The retracted stoma allowed the stool to
collect beneath the skin level and form the sinus tract which was draining
through his wound.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
shared my thoughts with Mickey and his wife and tried to formulate a plan to
correct the problem, something simple I hoped. Alas, it was to be everything
but simple.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Once
he was safely ensconced on the surgical floor at the hospital, Mickey stayed
mostly in bed and the bleeding abated. My friendly neighborhood
Gastroenterologist was consulted and colonoscopy scheduled.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
sat at Mickey’s bedside and presented my plan to him and his wife. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“It’s
a little earlier than I’d like, but the simplest way to fix this problem is to
reverse your colostomy,” I explained.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">They
were both in agreement, his colonoscopy checked out OK and surgery was
scheduled for the following day, Friday.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">It
was noon when Mickey was rolled into OR five. He scooted from stretcher to
table like a lithe teenager and, in short order, the operation began.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
midline incision was made and the peritoneal cavity entered in the upper
abdomen, above the area of his previous surgery and, I hoped, any adhesions.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe this won’t be too bad.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">As
if to punish me for having such thoughts I ran into the proverbial wall, or, in
this particular case, net of adhesions. Omentum plastered to colon which was
wrapped around small bowel which filled the pelvis. No blue sutures to tell me
where the closed off stump of colon was hiding, but also, no cancer.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Minutes
rolled into hours as I inched my way around bowels, omentum and adhesions,
finally spying one of my Prolene sutures after more than three hours of
chiseling away. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I’m supposed to be doing a
gallbladder in ten minutes.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Could
you please call ‘elsewhere hospital’ and let them know I’m late. I may be there
by four or four thirty,” I requested of my kind circulating nurse.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Maybe
doing this surgery earlier than planned was a bad idea,” I remarked out loud to
no one in particular.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“Looks
like we’re almost there,” my assistant commented as more blue suture popped
into view.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Sure
enough the blue sutures which would lead me to the closed off stump of rectum now
loomed large in front of me. A final snip freed the last loop of small bowel,
which was then examined from beginning to end and safely tucked away.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
now stared at a long tunnel which was Mickey’s pelvis. Down in the depths was
the object of my intentions: a stump of
rectum which I hoped would accommodate the EEA stapler.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
proximal colon was dissected free from the abdominal wall and the big moment
arrived.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
EEA stapler is a clever device which fires two rows of staples while cutting
out two donuts of tissue between the circular staple lines. This leaves an
opening between the two organs which have been stapled together. I find it most
useful for constructing anastomoses at the ends of the GI tract, those
involving esophagus or rectum.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">This
stapling device has a detachable part call the anvil which goes into one end of
the colon, usually the proximal portion. An opening is made and the anvil is
passed through this opening which has had a “pursestring” suture placed which
is tied around the “anvil”, closing the colon wall around this anvil.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I’ll get one shot at this, it better
work.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Mickey’s
bottom had already been prepped and I began the process of passing the stapler.
First the anus was stretched with a series of lubricated metal dilators up to a
size adequate to allow passage of the stapling device. After the device has
been inserted it is guided to the proximal end of the closed off rectum. The stapler
is then opened and a spike appears which pierces through the closed off rectum
and is connected to the anvil. The stapler is tightened and fired and then
withdrawn.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
big moment arrives as the stapler is opened and the donuts removed. In Mickey’s
case the donuts looked complete, but very thin on one side. I next checked the
anastomosis to see if it was airtight. I filled Mickey’s pelvis with water so
that the colorectal anastomosis was completely submerged. Next, I instilled air
into the rectum and watched for bubbles. If the colon inflates, but there are
no bubbles released, then the anastomosis is airtight. Bubbles percolating
through the water mean there is a hole somewhere. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Much
to my disappointment, a large number of bubbles appeared.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Now what? Do it again? You had one
shot and you blew it.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Maybe do another colostomy? But, what
about his big belly? Problems, problems, always problems. Only skinny people
should be allowed to get sick. At least they should pay us by the pound</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">“We’ll
need to do a transverse colostomy,” I announced to the OR crew.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
decided that creating a loop colostomy in the upper abdomen would minimize the
pendulous abdomen issue while allowing my newly constructed coloproctostomy
(colorectal anastomosis) the time to heal. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">The
new stoma was constructed with my usual workmanlike efficiency and Mickey was
closed up. I had spent five and a half hours in Mickey’s belly, battling large
and small bowel, scar tissue and fat. As I pulled off my gloves I felt a tightness
in my knee, a common occurrence after long surgeries which command my utmost attention
for a long period of time. Over the years I’ve discovered that cases like this which
require concentration to the extent that I forget to move or change position,
block out much of what is happening around me, be it my cellphone or music
which may be playing or the beeps and chimes coming from anesthesia’s machines.
The patient increasingly becomes my only focus as I become oblivious even to
the pain which grows in my knee.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">I
wish I could say that every patient requires such intense concentration, but
that wouldn’t be true. Most surgeries are straightforward and, thank God,
uncomplicated, such that this level of concentration is not necessary. If every
case was like Mickey, I don’t think I would still be practicing surgery.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">Mickey
recovered uneventfully. Three months later I checked his colon and found that
the anastomosis in his pelvis had completely healed. He underwent an
uncomplicated reversal of the transverse loop colostomy. I felt fortunate that I could stay out of his big
abdomen and avoid further skirmishes with his bowel. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: .5in; text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;">He
has remained cancer free to this day.<o:p></o:p></span></div>
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David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-10419655935197250462015-09-07T10:31:00.001-07:002015-09-07T10:31:55.253-07:00Firsts<div class="MsoNormal" style="text-align: right;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> </span><span style="font-family: 'Times New Roman', serif; font-size: 14pt; line-height: 107%;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="text-align: center;">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> </span><span style="font-family: 'Times New Roman', serif; font-size: 14pt; line-height: 106%;">Our lives are full of firsts.</span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">Parents wait for their baby’s first tooth, first words
and first steps.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">We may remember our first day of school, first solo
bicycle ride without training wheels, first automobile drive, first date, first
kiss, first sexual encounter and others that I don’t recall at the moment.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">A surgeon also has firsts.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">I clearly recall the first surgery I ever saw. Now,
you might think that because I am the son of a surgeon that my childhood was
replete with trips to the hospital with my father where I accompanied him into
the OR and became his right hand man at the age of thirteen. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">Not true. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">On rare occasions I did go to the hospital with my
father when he made rounds, but the closest I ever got to an operating room was
sitting on a bench outside the gift shop, watched over by the volunteer behind
the cash register while my father went upstairs to see his patients. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">There were occasional conversations at the dinner
table which delved into the world of surgery:<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">Dad: “Dr. A, the anesthesiologist, is getting a
divorce. Isn’t his wife, Betty, in your Bridge Club?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">Mom: “She’s the reason the bottle of Scotch is almost
empty.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">Dad: “Well, she was sleeping with Dr. K while Dr. A
went off and spent a weekend with one of the nurses in the OR.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">Mom: “I guess I’ll need to somebody new for the Bridge
Club, one who doesn’t like Scotch. Anything new at work?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">Dad: “My new office nurse is pregnant.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">Mom: “You mean the one who said she hadn’t been able
to get pregnant for two years? She’s only been with you for two months.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">Dad: “I guess some of the Gelber fertility rubbed off
on her,”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">Mom: “That’s the third nurse who’s gotten pregnant in
the last eighteen months. And, none of them had been able to get pregnant
before.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">Dad: “It must be something in the air.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">There have been many important “firsts” over the
years. I remember my first day of medical school when I was introduced to
Herman, my anatomy group’s cadaver, a constant companion through the first
semester and Sigrid, last name Gelber, my lab partner, adopted sister and
friend through medical school and afterwards until her death from breast cancer
at the far too young age of 35.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">Then there was my first day of Internship, a Sunday,
when I arrived at the hospital where I was greeted by a list of patients and
instructions from my second year resident to make rounds, do the necessary
H&P’s on the new admissions and he would see me the next day. This
particular resident, not surprisingly, was fired before the year was out and is
now tormenting surgeons as an anesthesiologist.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">It was in medical school that I actually witnessed my
first operation. I was assigned an advisor, Dr. C. Nelson, a Neurosurgeon. His
job was to smooth the transition from the rigors of college to the even greater
exactitudes of medical school. I don’t remember much of what he did, except
that he invited me to watch an operation. He was performing a transsphenoidal
resection of a Pituitary tumor the following day. Finally, something more than
the formaldehyde of anatomy and squinting into a microscope in Histology.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">I managed to find my way to the OR assisted by an OR
nurse who directed me to the locker room where I donned the blue surgical
scrubs of Strong Memorial Hospital, 60% Cotton, 39% Polyester and 1% stainless
steel. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">I managed to find my way to the OR room where the
operation was about to commence. I managed to come within six inches of
contaminating the scrub tech’s back table, while I looked upon the patient,
prepped and draped with her upper lip pulled back, exposing her teeth and gums.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“This patient has Nelson’s Syndrome caused by a tumor
in her pituitary gland,” Dr. Nelson explained. “We’ll approach the pituitary
through her sphenoid sinus, which is behind her maxilla.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">I nodded my head, then asked, “Is Nelson’s Syndrome
named after you?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“I wish,” he answered, “that was a different Dr.
Nelson.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">I watched as the Chief Resident began the surgery,
incising above the teeth, removing bone and finally reaching the pituitary
gland. An operating microscope was wheeled into position and Dr. Nelson began
the real operation. I was able to watch through a second teaching port.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">I saw some reddish tan stuff and then some yellow gray
gunk and then I saw Dr. Nelson tease the yellow gray gunk away from the reddish
tan stuff.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“The thin grayish tissue is the adenoma. She’s making
too much ACTH which is causing her adrenal glands to secrete too much cortisol,
resulting in her having Cushing’s disease.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“I thought you said she has Nelson’s Syndrome?” I
asked in my ignorance.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“Nelson’s Syndrome is causing her to have Cushing’s
disease,” he explained, displaying far more patience than I deserved.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">After a few hours the operation was finished. The
Chief Resident closed her up, sealing the surgical site with some fat and
superglue.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“It looks painful,” I commented as he glued the bone
back in place, while I considered what it would feel like to have someone cut
me along my upper gums.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“Surprisingly not,” the Chief Resident responded.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“How do you learn to do such an operation,” I wondered
out loud.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“I take notes, read about the technique, assist on
cases and then do the surgery,” he answered. “It’s all about studying and
observing.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">One thing he didn’t mention was innate talent. When I
finally began doing surgery I realized that natural ability and technical skill
was something that could be taught only to a certain extent. Truly great
surgical technicians are born, not made.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">It was years after this first experience with surgery
that I actually performed my first real surgery. It was my first month of
internship and I was on call when Peter was admitted to the “Resident’s”
service. He’d had pain for three days, with nausea, vomiting and elevated White
Blood Cell count. He had exquisite tenderness in the Right Lower Quadrant of
his abdomen. Peter was a textbook case of acute appendicitis.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;"> It was about
seven pm when my Chief Resident, Dr. S and his Attending, Dr. T. joined me in
the OR for Peter’s appendectomy. I had read the book on appendicitis and
studied the technique over and over.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">The surgical tech handed me the scalpel and I began to
make my incision.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“Your shaking like a Goddam Parkinsonian,” commented
Dr. T. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">I did shake a little, but not enough to interfere with
the actual surgery. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">Once the incision was made, I switched to the electrocautery
and buzzed the bleeders in the skin edge and then made the incision deeper
until I saw the diagonal fibers of the external oblique fascia. Just like in
the book I incised in the direction of the fibers and retracted this muscle.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“Take a Kelly clamp and split the muscle of the next
layer along the direction of their fibers. First with the muscle, then
perpendicular to it, so that it spreads apart. By the way, which muscle is
this?” Dr. S asked<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“Internal Oblique,” I answered without losing a beat.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“Right. If you didn’t know, then I would have to take
over the surgery,” He added.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">The Internal Oblique and Transversalis muscle fibers
were split apart exposing the peritoneum.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“Clamp,” I requested.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">The scrub tech slapped it into my hands, just like in
the movies.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">I picked up the peritoneum with the clamp.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“Another clamp for my assistant,” I said, a bit too
softly.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“What?”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“Another clamp for my assistant,” I replied, much more
loudly.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“OK, OK, you don’t have to yell,” the tech added.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">I opened the peritoneum and some cloudy fluid poured out.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“Culture,” I said loudly and I was handed a swab.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“Now, put your finger in and see if you can feel the
appendix,” Dr. S instructed.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“I feel something hard,” I replied.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“Let me check,” he suggested as he put his fingers through
the opening in the peritoneum. “That should be the worm (nickname for the <i>vermiform appendix</i>, the complete name
for the appendix); see if you can flip it up into the wound.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">I put my finger in and swept it around the offending
organ and it came into view. It was swollen to the size of a Hebrew National
Knockwurst.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“Don’t grab the appendix,” Dr. T. barked. “Find the
cecum.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">Years later another Attending surgeon, Dr. Bronsther
taught me this one surgical nugget about appendectomies, the only thing I ever
learned from him. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“Appendectomies are surgery of the cecum.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">What he meant was that the appendix always arises from
the cecum, which is the first part of the colon. It is always found where the
three Tenia coli, which are the three longitudinal muscle layers which are seen
on the colon, coalesce. Over the many years I’ve been doing appendectomies,
these two pearls of wisdom have served me well.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">Back to Peter. I identified the Cecum and gabbed it
with a Babcock clamp and delivered it up into the wound. Once enough of it was
protruding through the wound, I grabbed it with a sponge, rocked in back and
forth until the entire cecum popped into the wound, followed by the very
swollen and inflamed appendix.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">Now it was time to actually do the surgery, that is remove
the sick organ.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“Wait, wait,” Dr. S. said forcefully.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">The three of us stared at the swollen appendix,
greatly enlarged all the way to its base. The normal procedure would be to
divide the mesoappendix, which carries the appendiceal artery, ligating the
blood vessels, then divide and ligate the appendix close to the Cecum, usually
leaving a small stump. There was controversy in those days about inverting the
stump or merely tying it. The consensus was that simple double ligation was
appropriate. Inverting the stump potentially created future problems.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“Start with the mesoappendix?” I wondered out loud.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“Right,” Dr. S. agreed.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">We clamped along the fat which led to Peter’s appendix
and then tied each blood vessel within the clamp until the appendix was free
from any attachments all the way to the Cecum. There was a short segment, about
three millimeters, of normal appendix.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“Clamp it there?” I suggested, pointing to the
uninflamed stump.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“Yeah, but use a Kelly on the appendix side,” He
added.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">Clamp, clamp, cut and that sick appendix was gone.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“O Vicryl tie?” I requested, a touch of doubt in my
voice.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“Right,” my assistant agreed and we’ll need some 2-0
Vicryl stick ties, also.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">We tied off the appendiceal stump and then sutured the
cecum over this ligature. I admired my handiwork for a moment.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">“Put it back where it belongs, Dr. Halsted,” Dr. S.
ordered, “the patient’s not getting any younger.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">I closed him up, irrigating and suturing each layer
before stapling the skin closed. Peter was wheeled off to Recovery as I trailed
slightly behind holding his chart and sporting a big grin on my face. He went
on to an uneventful recovery.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">Years later, during an interview, I was asked about my
most memorable moments. I cited two:<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 106%;">My wedding day and Peter’s operation.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="text-indent: 0in;">
<br /></div>
<div class="MsoNormal" style="text-indent: 0in;">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="text-align: right;">
<span style="font-family: 'Times New Roman', serif; font-size: 14pt; line-height: 107%;"> </span><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 107%;"> </span></div>
David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-90499106332325483782015-08-26T18:57:00.001-07:002015-08-26T18:57:38.814-07:00Rat<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;"> <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">It was 4:45 on a
Wednesday afternoon, clinic had just finished and I’d be on my way home in
fifteen minutes, unless…<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Beeep…Beeep…Beeep”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Rats,
it’s the emergency room.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Dr. Gelber, we’ve got an
85 year old lady from the county nursing home with a distended abdomen. Could
you come and take a look at her?”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">So
much for going home on time. You think they could have waited fifteen minutes.</span></i><span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">I made my way to the
surgical side of the ER and found Madge. She was a wrinkled old lady, weighed
in at 102 pounds, white hair, black glasses which magnified sharp blue eyes.
Her most distinguishing feature at that moment was a belly that was the size of
a medicine ball.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Hello, Ms. W, I’m Dr.
Gelber. How long has your abdomen been so blown up?”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Glad to know you Dr. Gelber.
Call me Madge. This old belly’s been growing for the last five days. I think
it’s a boy.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Well, Madge, I think
we’ll need to deliver it soon,” I answered. “Are you having any pain, nausea or
vomiting?”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Her look turned a bit
serious as she answered, “Mostly pressure, not really pain and a little nausea.
And, I haven’t pooped in a week.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Passing anything out?
Gas, diarrhea?”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Nope, not a toot or
tweet for five days.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">She had a collection of
associated medical problems, typical for your average octogenarian. She had a
little hypertension, a bit more congestive heart failure, atrial fibrillation, myocardial
infarction a year ago, previous hysterectomy, nothing unusual, but enough to
cause the Cardiologist to say she was at considerable risk for complications.
She had mild abdominal tenderness, but her abdomen was tight as a ripe
watermelon and about the same size. Her heart was beating at a rate of 124,
blood pressure was 85/50.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Plain abdominal X-rays
revealed massively dilated colon. In particular, the cecum (first part of the
colon) measured eighteen centimeters in diameter, well beyond the 12 centimeter
diameter when one begins to worry about it bursting.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">I called my Chief
resident, Dr. J, who deferred to the Chief on call, Dr. B., who came to see the
patient and then disappeared. In the meantime I did all the paper work to get
Madge admitted and prepared to go to the OR.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Her diagnosis was acute
large bowel obstruction.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“At last I get to be
around some young blood,” she commented as I finished my H&P. “All the men
at AHP (the nursing home) are wet noodles, if you get my drift; you know soft
and limp. Maybe, when I’m better, you can show me around the hospital, Dr. G?”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Let’s get you better
first. But, I don’t think my wife would appreciate me carrying on.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“She’d never know.
Besides I don’t see any wedding ring.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">I glanced at my naked
finger. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“I don’t wear it. Too
much taking it off and putting it on. I’d lose it in a week.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Dr B. returned and he
said a cecostomy was in order, under local anesthesia.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“I guess you talked to
the Chief?” I asked. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Our Chairman, Dr. Di was
a staunch proponent of cecostomy in this situation.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">We took her up to surgery
and performed the cecostomy, which means decompressing her cecum by placing a
tube into it, under local anesthesia. The cecum was massively distended with
the muscle fibers of the outer layer split apart by the distension, but there
was no gangrene or perforation. It was the size of a volley ball. After it was
decompressed it looked much healthier. The tube was left connected to a
drainage bag and Madge went to the ICU. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Her journey was just
beginning.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Over the next forty eight
hours she stabilized. Her vital signs, renal function, lab abnormalities all
normalized. She was ready to embark on the next stage of her odyssey.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">The next step was to
figure out the cause of her severe distention. Based on the tests that had been
done, the assumption was that she had a mechanical obstruction on the left side
of the colon. The most likely causes would be a tumor or narrowing secondary to
diverticulitis. There was an outside possibility she had suffered from
Ogilvie’s syndrome, otherwise called colonic pseudobstruction, although the
initial X-Rays were more suggestive of a mechanical cause.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">She was wheeled from the
ICU to Radiology where she underwent a barium enema (BE), a test where a
radiopaque dye is instilled into the colon and X-rays are taken at various
points. This provides information as to the length, contour of the colon,
demonstrating areas of narrowing (stricture) or dilation. Large tumors also can
be seen with this test. Madge’s BE revealed an abrupt termination of the column
of dye in the distal sigmoid colon.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“She’s going to need
another operation,” I told Dr. B.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Try to prep her using
the cecostomy and we’ll try to do her surgery in three days.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">It fell on me and my
junior residents and interns to begin to flush her colon with saline every few
hours, attempting to clean the abundance of stool trapped within the obstructed
colon. The hope was that a clean colon would allow for a single stage resection
and anastamosis, avoiding a colostomy and the necessity that she wear a bag.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">It was a tedious job.
Instill a few hundred cc’s of saline and let it drain, add some more and let it
drain. At first it seemed hopeless as we kept getting some light brown saline,
but little else.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Through it all Madge
managed to keep her sassy edge.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“You know, Dr. G, when
I’m all better and back at the home you should come and see. I’ve got my own
room and it’s so cold and lonely at times. All the men there are just wrinkled
old prunes.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Let’s just get you well
first, Madge,” I answered.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Oh, I’m not worried
about that. You doctors here are so hard working and caring and conscientious.
Some are pretty sexy, too. I know I’ll be back on the dance floor in no time.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Were you a dancer,
Madge?”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Third prize in the
Queens borough ballroom dance off 1919. Leon and me knocked them over with our
cha cha. Poor Leon, he was killed a few years later; run over by a horse. He
was the love of my life, definitely not a dried up prune or a wet noodle, if
you get my drift.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">I smiled at her as I
finished my flushing of her colon.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“One of my interns will
be back a couple of hours. Sorry about Leon.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">She didn’t answer. She
was staring off at nothing, a smile on her face, lost in memories of Leon and
happier days.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">After four days and
flushing and draining, flushing and draining we pronounced Madge clean. By <b><i>we</i></b>
I meant my Chief resident, the Chairman of Surgery, myself, the second year
resident, the intern, four ICU nurses, the custodian and two cockroaches who
called the ICU home. Her surgery was scheduled for the next morning.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">It was a big event. Dr. B
was operating with the Chairman, with the intern and second year resident on
hand to provide proper retraction. I was left out to hold down the fort in the
rest of the hospital, but I managed to hover around the OR to see what was
happening.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">The surgery started
uneventfully, but, as the colon was examined the surgical team was greeted by a
left colon full of solid stool. The plan for a single stage resection and
anastamosis faded away in a column of poop as they went to plan B. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Madge’s sigmoid colon was
resected, the end was brought out to the skin as a colostomy and the distal
colon was closed off and left in the pelvis, a so called Hartmann’s pouch. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Madge came through the
surgery without a hitch and was wide awake and ready to flirt when I saw her on
afternoon rounds.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Did you guys give me a
nice flat tummy? I want to look good in my string bikini this summer,” she quipped.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“You’re already nothing
but skin and bones,” I answered, “but you do have a colostomy now, at least for
a while.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">She gave us a pout and
look of disappointment, followed by a shrug of her shoulders as we continued on
rounds. She had completed stage two of her journey. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Her recovery was
uneventful and she was back tormenting the male residents of the nursing home
in a little more than a week. She came back to the clinic a week later where
she was seen by one of the interns.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“An ole lady named Madge
is asking about you, Dr. G,” Intern reported. “She says you missed ballroom
night at the nursing home.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">I made my way into her
room.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“I really can’t dance,
Madge,” I confessed. “Dr. B, now he can dance.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Well, I guess we can
skip the dancing and go straight to bed,” she propositioned.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“I think you’re more than
I can handle, Madge.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">And, she went on her way.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">She made a second
appearance in the clinic a month later, looking quite well, eating, walking,
she even gained three pounds.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“When can I get fid of
this shit bag?” she asked.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">She was now about six
weeks post op and she still had the cecostomy tube, which was clamped.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Let’s get your colon
checked and then we can think about reversing the colostomy,” I explained.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Good, the sooner the
better. Even the old prunes at the home won’t give me the time of day with this
bag.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">I set her up for a
colonoscopy the following week, to be done by me, one of the last colonoscopies
I ever performed. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">As she was wheeling back
to the endoscopy suite she remarked:<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“You really know how to
show a girl a good time.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">I smiled, “We’ll take
good care of you Madge and we’ll get you all put back together as soon as we
can.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“I like a man who
whispers sweet nothings …” and she was out.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">The colonoscopy was
uneventful, revealing diverticular disease in the descending and proximal
sigmoid colon. She was scheduled for reversal of her colostomy ten days hence.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“We’ll leave her
cecostomy for now. It may add a bit of protection for her after the colostomy
reversal,” my Chief decided.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">At 7:15 am ten days later
Madge was rolled into OR room 12. Miss C, our cranky, dour, and very
experienced circulator and Mrs. J, our equally skilled scrub tech made up our
crew along with Dr. B, me and one of our interns. The Chairman, officially the
Attending surgeon on the case, sat nearby in the OR lounge. Dr. B was in the
last month of his residency and was functioning independently and was acting as
teaching resident on this case. I was to be the surgeon of record.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">And so it started. A
midline incision was made and we entered the abdomen, greeted by a few
adhesions to the abdominal wall which were quickly and easily dispatched. The
small bowel was examined and packed out of the way. The colon leading to the
colostomy was identified and freed from scar tissue. All that remained was to
find the other end of the colon, dissect enough of it so that the two ends
could be connected.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">It was like running into
a stone wall. Madge’s pelvis, where the elusive segment of colon resided, was
socked in, a mass of adhesions with tissues more resembling concrete than
colon.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Where’s the colon?<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Where’s the bladder?<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Where are the ureters?<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Where, oh where will I
dissect next?<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Let’s find the ureters
first,” I announced to no one in particular.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Good plan,” Dr. B
responded. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Starting higher up in the
abdomen away from the dense mass of pelvic scar I began my search. The proximal
colon which led to her colostomy was freed from adhesions first. Behind was a
mass of small bowel. I commenced the tedious dissection of this small bowel.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Do you really need to
free up all the small bowel?” Dr. B asked.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“You know the rules:
either you leave it all alone or cut away all the adhesions,” I recited.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Ok, Ok,” he answered.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Like the barber/surgeons
of old I began to snip and trim, starting where it was easy and them moving
along centimeter by centimeter until, an hour and a half later, all the small
bowel was free. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">This actually was very
helpful. Some of the bowel, as expected, had occupied the pelvis and now it was
liberated and safely tucked away in the upper abdomen.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">(I have to comment on my
terminology, specifically the term liberated. It’s a bit tongue in cheek. I
remember reading an operative note for a colon resection. The surgeon dictated
that “the splenic flexure was liberated…” I immediately had visions of colons
running through the streets chanting, “I’m free, I’m free…” the term “liberated”
in this context always brings a smile to my face.)<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Progress was slowly being
made. With small bowel out of the way, the ureter was easily identified. The foley
was palpable within the bladder and careful dissection behind the bladder
revealed a staple line; the staples within the closed off end of the colon.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“I think I just need to
dissect enough to be sure that there is only colon, no vagina or bladder”, I
concluded.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">My Chief disagreed.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“You need to be sure it
is free enough so there is not tension and adequate blood supply,” he answered.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">I disagreed, believing
that the more the distal colon was dissected, the greater the likelihood that
blood supply would be compromised or a nearby structure would be injured. But,
I complied with his wishes. He was, after all, more senior, more experienced
and had the power to make my life miserable should he so choose. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">With the ureters safely
in view and the bladder now out of the way I worked on the colon and rectum. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">First, straight down to
the sacral prominence, a safe area where there were no vital structures. Then
in front of the colon, separating it from the posterior vagina.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Is this free enough,” I
wondered out loud, clearly conveying my view that it was more than enough.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">I received nod of
acquiescence.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">The colostomy was quickly
freed from the skin, the actual stoma was resected (removed) to provide a clean
end to anastamose to the distal colon. It was immediately apparent that the two
ends would not reach each other. More dissection of the left colon followed,
which meant liberating the splenic flexure (there’s that image again) which
allowed the two ends to meet.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Use the EEA?” I asked,
requested, implored.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Hand sew. You know what
they’ll say in conference,” Dr. B replied, alluding to the required
presentation of the case at one, or several, of our weekly meetings where the
cases done that week were presented and discussed.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“And, I’ll take the
heat,” he continued, “not you.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Ok, I’ll sew it. But it
won’t be easy. We’re pretty far down in the pelvis.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">I did my best to put the
two ends back together. First the back wall of interrupted silk sutures, then
the inner layer of continuous Vicryl, an absorbable suture material, and,
finally, the outer front layer of silk. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Each suture placement was
a chore as I endeavored to be precise; to be sure I caught the full thickness
of the bowel wall, while not compromising the lumen diameter. When I finally
finished, something just didn’t feel right.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“You know,” I commented,
“something isn’t right. I just can’t be sure that the two ends have come
together properly. Do you think the cecostomy will provide some protection for
the anastamosis?”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“You know it won’t,” Dr.
B replied.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Well, I just don’t trust
my anastamosis. Maybe we should do a proximal colostomy?” I wondered out loud,
a bit facetiously.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Dr. B didn’t say a word
at first. I suspected he was wondering if he should call the Dr. Di, the
Chairman of the Department and the official Attending on the case.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“I’ll be back in minute,”
he said and he broke scrub. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Dr. Di agrees. We should
do a transverse colostomy,” he announced when he returned.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">While he scrubbed his
hands again, I mobilized the right transverse colon and we created a transverse
loop colostomy, fashioned so that it functioned to completely divert the fecal
stream away from my pelvic anastamosis. We closed Madge up and she woke up
without a problem, after five hours of surgery. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">She sailed through the
post operative recovery. Stage Three was over. She still wasn’t finished,
however. Now she sported a tranverse colostomy and the cecostomy was not completely
closed either. She was going to need at least one more surgery. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">A month later I was
walking past one of the exam rooms in the surgery clinic when I heard a
familiar voice.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“There goes my young
stud,” she cackled. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">I made an abrupt U turn
and went into the room where Madge was being checked by one of the interns.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“You know I’d be with you
in a minute, Madge,” I answered, “but I’m spoken for.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Another broken heart,”
she replied, “and I’m stuck with dried up prunes. And, I still have to wear
this bag.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Let’s see,” I mused as I
perused her chart, “it’s about six weeks from the last surgery. I think we may
be able to do something about that in the next few weeks.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">I was Chief Resident now,
so I went to talk with Dr. Di., who agreed Madge could have her next procedure
in two or three weeks.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">I examined her again that
day. Her midline wound was healing well, the colostomy looked pink and healthy,
but the cecostomy site still had not closed completely. There was a five
millimeter open wound with some mucus draining.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“It’s getting smaller,”
Madge commented, “doesn’t hurt a bit.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">She was scheduled for the
seventh, which was in three weeks. Orders were written and she went on her way,
with plans to be admitted to the hospital on the sixth, the day before surgery,
when she would have all the necessary preoperative preparation.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">The big day came and
Madge said she would be happy to be rid of the bag. Of course she took the
opportunity to offer herself to me one more time.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“After this surgery you
must stop by and see me in my rook over at the home, Room 202. Every night it’s
the same routine: dinner, television, the sounds of arteries hardening and
saliva dribbling. Come by and see me. We can go dancing.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">And she winked at me as
she was rolled into Room twelve.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">This surgery was a
straightforward closure of a loop colostomy. The actual surgery was done by my
fourth year resident with me acting as teaching assistant. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">The incision was made
around the stoma and the dissection carried down into the subcutaneous tissue. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Did you take your slow
pill today?” I wondered out loud. My junior resident, Dr. T., was moving like a
glacier, one cell layer at a time.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Open your eyes and see,”
I suggested. “There is a plane of dissection between the colon and the
subcutaneous fat. The mesentery and the subq fat look different and, look, god
has left a white line which says ‘cut here’.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">With a bit of guidance
the fascia, the layer below the fat was finally reached.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Now, dissect along the
fascia so that the colon can be liberated (there’s that word again),” I
instructed.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">My words were greeted by
a lost stare out into space.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Right angle clamp,
please,” I requested.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">I hated to do it, that is
take over the dissection, but, poor Madge was not getting any younger.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">I dissected the colon
free from the fascia using the clamp, allowing my junior resident to cut in
between the jaws of the clamp, which provided some semblance of “doing the
case.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">The colon finally free,
it was delivered up into the wound and continuity restored via a two layered,
sutured, side to side anastamosis. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“What next?” I asked as
the fourth finished tying the final silk suture.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Put it back inside,
close her up and then make rounds?” he answered.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Well, some people would
consider that a right answer. If I were actually doing the surgery, I would
tack some omentum over the sutures lines. It adds an extra layer of protection,
although the way Madge handles surgery, I think you could have used paste to
put her back together and it would have healed just fine.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">The surgery finally done,
after four tedious hours, Madge was tucked away in the Post Anesthesia Care
Unit and proceeded through another smooth and uneventful recovery.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">She did manage to
proposition me on a daily basis until she was discharged once again.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">I thought she was done
with surgery. Four stages for the treatment of a colon obstruction was a bit
unusual. One of the frequent discussions/controversies in general surgery was
how to handle acute large bowel obstruction. Should it be a one stage procedure
with resection of the offending segment of colon coupled with some sort of on
the OR table bowel cleansing, a two stage procedure with resection of the
diseased segment and creation of a temporary diverting colostomy, followed by a
second operation to restore colonic continuity, or a three stage procedure with
an initial diverting colostomy, a second operation to remove the cause of the
obstruction and then a third procedure to reverse the colostomy.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Dear Madge had undergone
four stages.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">I saw Madge in the clinic
a week later, healing quite well, eating normally, having normal bowel
movements and overall quite satisfied. Her only complaint was persistent
drainage from the cecostomy site.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“It should close, just
give it some time,” I reassured her.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“I’m sure it will, Dr.
G,” she replied and then she smiled at me. “of course, It might be best if you
came to check on it over at the home a couple of times a month.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">I smiled back. Good old,
dependable Madge.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“I think your coming to
the clinic will be adequate,” I answered.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Stuck with all the old
prunes,” she murmured.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">I saw her again a month
later. She was still draining from the cecostomy site. As a matter of fact, the
open area looked larger, with a bit of intestinal mucosa poking out.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“It looks like you’ll
need another surgery to close up the cecostomy,” I informed her.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">She shrugged her
shoulders and nodded her approval. Then, as if sensing some disappointment on
my part, she added, “Can I have a private room this visit? One never knows when
a handsome young red headed doctor will come calling and try to take advantage
of a girl.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">I smiled and said, “See
you next week.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">The surgery came and went
off without a hitch. My second year resident performed the surgery while I
acted as teaching assistant.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">We dissected around the
cecum, following it down to the fascia, cutting away all the scar tissue and,
finally, delivering the cecum into the wound. There was a 1.5 cm hole which was
closed in two layers, then reinforced with a bit of fat before it was dunked
back into its rightful home within the peritoneal cavity. We closed her up and
she went to the PACU, for the final time, I hoped.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Sure enough, except for
shifting her affections from me to the younger and handsomer junior resident,
her post operative recovery was smooth sailing.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“I’m a little
disappointed, Madge,” I explained to her on the day she was discharged, “you
seem to have shifted your amorous affections from me to Dr. K.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Well, Dr G., I’m not
getting any younger. You had your chance and you blew it. Besides, Dr. K is
really hot,” she answered.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Good luck, Madge,” I
responded. “And, I say this with all affection, but, I hope I don’t ever see
you on my OR table again.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">She smiled and nodded her
understanding, but then added, “Do you have Dr. K’s phone number?”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“You’ll have to ask him
yourself. I’m sure he’ll be around to see you before you leave.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">She sighed and then
added, “I guess it’s back to the prunes.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">I did see her back in the
clinic about a week later, one last time. She healed without a problem and
thanked me for helping to save her life.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Her case had been
different than most. There was no discussion about one stage, two stage or
three stage procedures.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">Madge had undergone a
five stage procedure.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">A few weeks later I had a
meeting with our Chairman, Dr. Di, and I brought up her case.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Remember Madge, the old
lady who had the large bowel obstruction and had the five stage colon
resection?” I asked the Chairman.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“She was a rat,” he
answered, his response taking me by surprise.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“I thought she was very
nice,” I answered.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“I don’t mean a rat, as
in James Cagney, ‘you dirty rat’, sense,” he said in his grandfatherly tone.
“No, I meant she’s a rat because she could be operated on over and over and
never turn a hair.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">He explained further.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Years ago there was an
experiment done. A number of rats had surgery, all the same sham operation.
After the first operation, some of the rats died. The survivors were operated
on a second time and a few more died. The third time a few more. But, after a
number of operations some of those rats just went on like nothing happened. You
could operate on those rats every week and they wouldn’t turn a hair. They just
woke up and went on their way. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman",serif; font-size: 14.0pt; line-height: 115%;">“Madge was a one of those
rats.”<o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="text-indent: .5in;">
<br /></div>
David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0tag:blogger.com,1999:blog-7390143371399216733.post-79503152067940212452015-06-28T15:16:00.001-07:002015-06-28T15:16:58.901-07:00Fourth of July<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;"> <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">I was a newly minted second year resident and it
was my second night taking call at the county hospital. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<i><span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">I
am ready for anything, </span></i><span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">I thought.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Call ER, Dr. Gelber”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">It was 9:15 am.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“We’ve got a fifty year
old male with a stab wound to the abdomen,” the ER attending reported.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">And so it started.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">I made my way down
there and found Jose. He was stable and there was a two cm wound just above his
umbilicus. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">In those days we
usually locally explored the wound and if it penetrated the peritoneum the
patient was explored. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">I called for some local
anesthetic, an instrument tray and some retractors. Just as I had learned as an
intern, I extended the stab wound and followed it down, down, down, deeper into
the abdominal wall. Through fat, then fascia, then muscle, then more fascia I
explored. After five minutes I found peritoneum and the stab wound kept going.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<i><span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Looks
like he’s going to the OR.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">We, that is myself and
my interns, got him typed and crossed, started antibiotics and called my Chief,
a fourth year resident.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“I’ve got Jose here
with a stab wound to the abdomen, penetrates the peritoneum. I think he needs
to go to surgery. He’s stable and he should be ready whenever you are.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Twenty minutes later,
off he went.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<i><span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Maybe
I can finish some of the work I need to do. Write some progress notes, check
some X-Rays.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Beep…beep…beep”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<i><span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">ER
again?<o:p></o:p></span></i></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Twenty nine year old
male with a gunshot to the chest and abdomen just rolled through the door.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“I’m on my way,” I
answered. I then started my fast walk back down to the ER. Sometime during
medical school I decided that there are very few emergencies that require me to
run. If the patient is so sick that I have to be there ten seconds sooner, then
he probably wasn’t going to survive, no matter what I did. But, I can walk
pretty fast.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Miguel was rolling into
room 4 as I arrived. He was awake with a BP of 90/50, heart rate of 110. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Do you have any
medical problems?” I asked, “Any allergies to medicine? Do you take any
medicine regularly? Any surgery for anything in the past?” Can you tell me what
happened?”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“I was sittin’ on my
porch reading the good Book when these two dudes came up and shot me,” he
explained. “Bam. I wasn’t doin’ nuthin.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“What about any other
medical history?” I asked again.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“No, I never go to the
doctor, ain’t never been sick, don’t take no meds or drugs. Don’t drink o’
smoke,” he answered.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Ok,” I sighed. “let’s
get another IV going, and get him a gram of Mefoxin.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">I gave him the once
over. He had one wound in his right chest which exited his right lower back and
a second wound in his lower abdomen which went straight through. Tattoo’s
extolling the virtue of his mother and his love for Angie adorned his chest and
back. A large scar ran from his left shoulder to his mid forearm.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“What’s this scar from?”
I wondered out loud.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Cut myself shavin’,”
he answered and then he smiled.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Type and Cross for
four units PRBC’s. Let’s get a single shot IVP to make sure he’s got kidneys
and I’ll need a chest tube tray and he’ll need a Chest X-Ray,” I barked out,
hoping either the nurse or my intern was paying attention.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">I called up my Chief
again. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Gunshot wound to the
chest and abdomen for you,” I reported. “I’m about to put in a chest tube and
then we’ll take the picture for the IVP. He’ll be headed your way in about
thirty minutes or so.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">And so it went.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Andrew came in with a
stab wound to the right chest, the result of him losing an argument over a
girl. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">He earned a right chest
tube and entered the queue to go to surgery.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Next came Miriam,
complaining of severe abdominal pain. She said it started after she had rough
sex with her boyfriend.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“How rough,” I asked as
politely as I could.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Well, I was laying on
the bed like this…” And she spread her arms and legs. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“…and Billie, that’s my
boyfriend’s name, was at the foot of the bed and he jumped on top of me. I got
the wind knocked out and then my belly started hurting really bad.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Did Billie come with
you?”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“I’m right over here,
doc,” a voice called from the doorway.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">There was Billie, about
six foot three, at least three hundred pounds.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Is that what
happened?” I asked.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Just like she said,”
he replied.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">I palpated her abdomen.
She was diffusely tender, more in the left upper abdomen. I looked at the
monitor: heart rate 130, BP 100/60.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">I turned to the nurse.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Give her a liter of LR
and send blood for type and cross and I need a peritoneal lavage tray.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">The nurse pointed to
the cabinet, intimating that I should help myself to the tray.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">I walked my intern
through the procedure. As she slipped in the lavage catheter bright red blood
shot out.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“I’d call that
positive,” I observed and we pulled the catheter out.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">I called my Chief again
and Miriam was whisked away to the OR.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">I had just made it up
to the ICU to check on some of our other post op patients when my beeper went
off. The number for the ER popped up.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<i><span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Will
it never end?</span></i><span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;"> John arrived, hypotensive, complaining of
severe abdominal pain. He’d stayed drunk for most of the last three weeks and
now he had all the findings of severe pancreatitis. He was admitted to the ICU,
required intubation and ventilator support and was dead six days later. Over the course of his illness he exhibited
ten of Ranson’s eleven criteria for predicting mortality from severe
pancreatitis. Six or more and mortality is predicted to be 100%.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">It was four in the
afternoon now and I sensed a lull in the stream of sick and injured. The day
wasn’t half over and I’d already done a week’s work.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">My Chief called and
asked me to come up to the OR where they were about to wheel Miriam in to Room
four for her surgery.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Dr. M is taking a
break. Come and do this case with me, that is if the ER has settled down.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Seems quiet at the
moment. I’ll be there in a minute.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Performing surgery is
always the best part of being a surgeon. I hustled over to the OR and we spent
the next hour and half taking out Miriam’s spleen. At surgery it looked like
the spleen had exploded, leaving bits and pieces held together by clotted
blood.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<i><span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">I
hope Billie let’s her be on top from now on.</span></i><span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">No sooner had I tucked
Miriam away in the Recovery room when my now despised beeper went off and the
familiar number to the ER appeared. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“<b><i>Five </i></b>MVA’s? Give me a
break,” I cried, but then headed down to the ER where I spent the next twelve
hours.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">They were waiting for
me, five patients strapped to back boards, faces splattered with blood and bits
of glass. Their car had driven off a bridge and plunged about fifteen feet into
a ravine.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Chest X-Ray, Femur
X-ray, Pelvis X-ray, CT of head, C-Spine X-ray, start another IV, Type and
crossmatch. Let’s go, let’s go. And so we went, nurses and my two interns sat
with the patients as they made their way from the ER to X-Ray to the CT Scanner
and then back to the ER. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Fractured femurs,
fractured tib fib, fractured pelvis, right pneumothorax, left pneumothorax,
tension pneumothorax, multiple rib fractures all made an appearance in one of
those patients. Call Ortho, call Neuro, call Urology. And with all the
injuries, none of those five needed a general surgery procedure outside of a
chest tube.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">No sooner had I
finished shipping the last of the MVA’s off to ICU when Eli came in by
ambulance, Gunshot wound to the head. He was breathing, but very shallow, heart
rate was 100 and BP was 100/60. There was dried blood on the right posterior
scalp and the defect in the skull was palpable. He did not move the left side
of his body.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">He was intubated with
the help of a friendly Nurse Anesthetist and was taken away for CT of his head,
one of my interns babysitting. With everything else relatively quiet I kept my
eyes on Eli and my intern.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">The CT revealed
extensive injury to the right posterior brain with bits of bone and bullet
mixed in. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">I called the
Neurosurgeon on call and then prepared Eli to go to OR where he was to have the
wounds debrided and ventriculostomy inserted. It was now 8:06 pm and the
admission count stood at eleven. The night was still young.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Eight thirty came and
went without another call, but eight thirty three brought two more stab wounds,
one with multiple abdominal wounds and the other with one to the chest and each
arm.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Back to the routine:
“Tell me what happened? Do you have any medical problems? Any surgery in the
past, any allergies, do you smoke? Drink? Use drugs? Take any medications?”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">The abdominal wound was
easy to assess as a big wad of omentum was hanging out one the abdominal wall.
Antibiotics, type and cross and off to the OR. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">The second one had a
hemopneumothorax and superficial wounds to the arms. A right chest tube
delivered 800 cc blood and then nothing more. The patient was stable, the post
chest tube X-Ray looked good and, with any luck, would not need any further
intervention. He was trundled off to the intermediate care unit. ICU beds were
becoming precious. Two more bad patients and I would need to go begging for
beds in the Medical or Cardiac ICU’s.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">As if on cue the ER
called again. This time it was Barbara, fifty years old with right lower
quadrant abdominal pain, nausea, vomiting, elevated white blood count.
Everything to suggest acute appendicitis. I called Sara, one of the new
interns, to go and evaluate her with the promise that she could do the surgery
if Barbara truly seemed to have appendicitis.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Just as Sara ran off,
the ER called again, gunshot wound to the leg was coming in. George, the other
intern, and I arrived in the ER just as Maurice was being wheeled into one of
the trauma rooms. He was awake and screaming. There was a big gauze bandage
soaked in blood wrapped around his leg. I started my usual banter and he just
screamed, the scent of alcohol permeated the room.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Let me look at your
leg,” I requested with a bit of force in my voice.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Get the fuck away from
me,” he answered. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“How about your foot?”
I asked.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Fuck off.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">I took that as a yes
and looked at his foot which was cold, blue and almost lifeless.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Maurice, I am sorry to
tell you that you need to have surgery. It looks like the bullet has injured
you femoral artery. If you don’t have surgery you will almost surely lose your
leg,” I informed my belligerent patient.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Fuck you.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Does that mean ‘fuck
you, I want surgery’ or ‘fuck you, I’d rather lose my leg,” I asked him.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">He calmed down for a
bit and agreed to surgery and allowed me to finish my survey of him and his
injuries. A few minutes later he was up in surgery.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">My pager went off
again, only this time it was the OR calling. Sara was ready in the OR with
Barbara and her appendicitis. I was to assist her, as the Chief was tied up
with our stream of trauma patients. I was happy for a respite from the ER,
which had reached a brief lull. I made
sure no one was waiting that might need surgery and that there were no injured
parties on the way and then I made my way to OR 5.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">It was 10:15.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Barbara’s surgery took
about an hour as I walked Sara through the appendectomy. She did a fair job. Of
course my reprieve from the ER couldn’t last. I had just lain down for a break
when the call of the ER came again.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Another stab wound to
the abdomen. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Back to the ER where I
found Drew, nineteen years old, BP 70/40, heart rate 140, conscious, but
barely.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Need to intubate him
and start another IV,” I commanded, going into captain of the ship mode.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">The nurse anesthetist
easily slid the endotracheal tube in, we ran in a couple of liters of Ringer’s
Lactate IV fluid and he perked up a little. Blood pressure came up to 90/60 and
heart rate fell to 120.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Poor Drew had a two
inch wound in the mid abdomen just above the umbilicus with a small amount of
blood pooling. He was pale and thin and palpation in the wound went all the way
in the peritoneal cavity.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Blood was hung and I
put the call into the Chief.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“This patient needs to
go right away. He arrived hypotensive and we’ve got blood hanging now,” I
reported.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Just finished one,
three still are waiting, but they’re stable. We’ll come get him now. Keep up
the good work,” he answered.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<i><span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">A
nice little pat on the head. It’s two am, the bars are just closing.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Why do people feel the
need to assert their manhood when drunk? Closing time until about three am is
prime time for trauma. Drunk and disorderly takes on new meaning as the nightly
revelers leave the safe confines of the pub and saloon and wander into the
street. Knives, fists, clubs and guns raise their menacing heads.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Hey, it’s the Fourth
of July…no, it’s now the Fifth of July…people have been partying all day and
night. I don’t think there will be many more,” I lied to myself out loud.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Like clockwork the ER
called again.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Two drunk guys with
stab wounds, one in the neck, the other in the abdomen, Both look pretty
stable.”<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">I made my way back to
there just in time to see the ambulance wheel I a young boy, five years old
complaining of severe abdominal pain after being assaulted by his mother’s
boyfriend, thrown against the bathroom sink.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Devon looked up at me
with bright blue eyes and winced if I even lightly tapped his abdomen. He was
otherwise stable, although a little tachycardic with heart rate 120.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">I also quickly
evaluated my two stabbing victims, who, it turned out, had stabbed each other
over the matter of twenty dollars and a pool match. The neck was mid neck, had
penetrated through the platysmal layer and would best be treated with
exploration. The abdominal stabbing also penetrated fairly deeply and would also
need to go the OR.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">I talked with the Chief
again, who came to evaluate the child. As I was talking with him my intern put
up the boy’s Chest X-ray which revealed free intraperitoneal air. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“One more for the OR,”
I stated. My Chief just sighed.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“How many is that?” I
wondered out loud. We’d both lost count.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Over the next few hours
three more MVA’s arrived, all with a variety of fractures: ribs, femurs,
humerus, tibias, fibulas, but nothing that would need general surgery. I tucked them away to await their Orthopedic
procedures and then went to make morning rounds. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">It was six am.<i><o:p></o:p></i></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">With my two interns in
tow we started in the ICU, visiting the myriad pre and post op patients whom we
had met in the twenty four hours we’d been on call.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">As we finished my Chief
called.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">“Dr. M is tired and
he’s leaving. We’ve got three more patients to explore. The stab wound to the
neck, and two stab wounds to the abdomen. Come on over to the OR so we can
knock these out.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">So after spending
almost an entire day in the ER I finished up in the OR, Exploring a neck which had only a lacerated anterior
jugular vein and a tiny tear in the thyroid cartilage, then doing exploratory laparotomies
on two patients where I repaired six holes in the small bowel, resected a short
segment of colon and did a colostomy.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">We checked on a few of
the sicker patients before we left.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">It was 3:25 in the
afternoon.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">By my count I had
admitted twenty five patients, mostly seriously ill and injured.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Jose had suffered
injury to his liver, colon and mesenteric artery. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Miguel had been shot in
the colon, stomach and pancreas.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Miriam had shattered
her spleen after her three hundred pound boyfriend had jumped on her spread
eagled naked body.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Maurice had suffered
injury to his right femoral artery and vein. His leg was saved, but that didn’t
improved his personality at all.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Eli survived his
surgery, but succumbed forty eight hours later.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Drew survived injury to
his diaphragm, stomach, spleen and left kidney, walking out of the hospital
after a two week stay.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">Devon suffered a
perforation of the third part of his duodenum and a laceration of his pancreas.
Timely surgery allowed the injuries to be repaired and he recovered
uneventfully. His mother’s boyfriend went to prison for five years.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 14.0pt; line-height: 115%;">All in day’s work.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
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David Gelber MDhttp://www.blogger.com/profile/09204825961979794522noreply@blogger.com0