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.
[Image source]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.