Midnight Save

My upcoming newspaper column, a respite from the current reality:

Offering a break from Kremlin on the Potomac, here’s a story modified from my Surgeonsblog days.

If I hadn't just finished a midnight appendectomy, Opal would have died. Not entirely canceling the bad luck in her life, she began her exsanguination when a surgeon and staff were immediately available. Vomiting all that blood, she was close to death when the ambulance arrived. 

Niceties like passing a scope to find the source go out the window when someone is bleeding to death from her stomach. I'd gotten the urgent call about a patient in extremis as I was writing post-op orders for the previous patient. After telling the team to expect more business immediately, I flew down the stairs to the ER to meet Opal, who wasn't in a position to be sociable. In shock, confused, retching blood, she also showed physical side-effects of high-dose steroids, which she was taking for some mysterious disease. Whatever I might do, those drugs would surely limit healing. And you can't stop them abruptly after surgery: it might cause physiological collapse. 

One thing about operating on the hypercritically ill: when you start from zero, there's no downside. She's going to die unless I can do something. No decision there, and, in a perverse way, no pressure: it’d be hard to make things worse. Which is not to say I'm cavalier. I know I'm the only hope she has. 

Based on the odds, I expected a bleeding duodenal ulcer, the surgical approach to which is generally quick and comparatively easy. Not Opal: likely due to her steroids, she presented me with two enormous ulcers encompassing most of her stomach, one of which had eaten through the back wall of it and into the splenic artery. No wonder she was bleeding so massively: that's a big one. One of my surgical teachers used to say, jokingly, not to worry about bleeding unless you can hear it. This I could hear. In order to stanch the flow, giving the anesthesia team a chance to fill her tank back up, the first step was to press my finger to the hole in the artery; and then I stood there, a warm-blooded cork. Several bags of blood and saline later, I placed sutures on either side of my finger, around the vessel. Dryness: silent and welcome dryness. Now what? 

Even when unavoidable, operating on someone in shock is not a good thing: it necessarily adds to the trauma, even as it seeks to reverse it. The least you can do is the best you can do. But Opal was in a fix. Having eroded nearly to the point of perforation, those ulcers were too treacherous to leave; plus, I might have just killed her spleen. So, having no lesser options, I chose to remove her entire stomach and her spleen, fashioning a sort of stomach-substitute reservoir out of intestine and connecting it to the end of her esophagus. Too much surgery, really, for such a sick and medically depleted lady, and I went fast as possible to minimize her anesthesia time. Despite my having told the family to expect a challenging stay in intensive care, with death a real possibility, Opal recovered without complications, thanks in no small part to great care from excellent nurses. 

Her life was tough: she lived in a half-hovel, to which I made many visits over the next several years, as she'd call with some concern or another and I'd go see her to do what I could. Every Christmas there’d be a card from her, thanking me for another year of life she'd have missed, had we not met. 

Several years later Opal underwent a major operation by a different specialist, and once again nearly died. Not directly involved, but feeling somehow responsible, I visited her daily in the ICU and painted an appropriately grim picture to her family. Yeah yeah, they seemed to say. Heard it all before. And darned if she didn't make it again. This time around, though, she had major healing problems, and I became a pro-bono de-facto visiting nurse, debriding her wound for weeks at her sad little home. I guess I didn't want those Christmas cards to stop. They did, eventually, but not for a few more years.  

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A Winter's Tale

My latest newspaper column, heavily modified, for space, from a seasonal post back in my Surgeonsblog days.

It was exactly ten years ago today. On emergency backup, I was called in to see a man with an unusual injury. It was the middle of the night, and I wasn’t particularly pleased. Reading his chart before going into the room, I could hear the man referring, it seemed, to every nurse within shouting distance as a "ho'." So I must admit I was a little rude to him. Just lifted up his garish shirt and had a look (what was this guy, a pimp? He called me a "ho," too. Several times.) 

Occupying the entire circumference of his enormous belly was a band of mottled skin, maybe five or six inches in width, oozing, and dirty. Despite wearing gloves and boots and the most ridiculous pants I'd seen in a while, the man was hypothermic. Given the potential for rapidly progressing infection, the dead skin needed to go. I put in a page for Larry, the anesthesiologist, and called the OR. "You're going to hate me for this," I told Larry. "He's huge, I'm going to have to reposition him two or three times during the case, and he has an enormous beard [anesthesia folk hate beards]. "Great," said Larry, as he hung up the phone. 

By the time I next saw my patient, they'd removed his clothes and put them in a couple of bags. Boots, gloves, heavy coat with fur-crested sleeves (who wears that? Heard of PETA?); and now, in the warmth of the room the stuff smelled like a barn. Larry was much more mellow than I, probably getting a laugh over my obvious displeasure. He gave the man the usual once-over and piloted the gurney to the OR. It took four of us to move him onto the OR table. He'd told us he was two-eighty, but he was three-fifty if he was an ounce. 

I won't belabor the surgical details. Suffice it to say it was unpleasant. Rolling the man from side to side, to Larry's grumbling (he'd crossed over to my mood half way through), I cut away a belt of skin and subcutaneous crud which, had I been able to do it all in one piece, could have wrapped twice around a telephone pole. It had taken the poor nurse fifteen minutes to scrub clean the man's stomach: No running water where he lives? Everyone had his or her own reason to be repulsed by the whole thing. After I finished, having assured myself it looked like he'd wake up, I went to take a shower. 

When I came back to the recovery room, the man was gone. 

Kathy, the world's best recovery nurse, seemed uncharacteristically befuddled. "What happened?" I inquired (you might call it). "Where's my patient?" I was ticked: I hadn't yet decided whether to send him to the floor or the ICU. Who'd made that decision without me??  

"He checked out," Kathy said. "Checked out? What are you talking about?? He died??"  

"No. I mean he checked out. Pulled out his IV, insisted I take off his bandages. Said he had important work to do that couldn't wait. He said he'd been so cold in the ER he couldn't even remember who he was, could barely talk."  

"You gotta be kidding. There's no way he... How could you let him...”?  

"I don't know. He just talked me into it, like I was a child. I just went blank, like he..."  

"Oh, man! This is bad. He's gonna die out there..."  

"I know you won't believe this, but he looked great. And the wound? It looked like it was healing already. Almost like it never happened."  

"Jeez, Kathy! We gotta..." 

"Sid?" Kathy asked as I tried to storm out the recovery room door.  

"What??" 

"How about his story? About how he got the injury?"  

"What story? I didn't even hear the story. What story?"  

"Getting stuck in a chimney, being pulled out by some animals. They were trying to slay him, I think he said. Oh, and he left these for you," Kathy grinned, tentatively, as she handed me half a dozen wrapped boxes.  

"Yeah, right. Keep 'em. The man is nuts. I gotta get home and get Danny's presents under the tree before he wakes up. Merry frickin' Christmas."  

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