anonymous

8th January 2020

Patients are the best teachers - The Human Spirit

Patients are the Best Teachers

The Human Spirit

 

Think I'm going to lose it." I had to step away from the operating room table for a few seconds. One gloved hand massaged my stomach; the other reached blindly for a wall. The stench was seeping through my surgical gown and gloves. "Damn.” I was gasping for some fresh air. "This is bad." I started to make my way back over to Maria, the patient on the operating table. "Nurse, put more of that smelling stuff on the tip of my mask near my nose, otherwise someone else is going to have to finish this operation. The odor from Maria's open abdomen was overwhelming.

Doctor, do you want a new gown, or another pair of gloves?" the scrub nurse asked.

"No thanks, Lori." I bumped my waist up to the edge of the operating room table. "It won't make any difference how many pairs of gloves I have on with this case." I paused for a second. "Okay, let's go. I don't want her dying on me in the room. More laparotomy pads." I stuck out my open right hand, grabbing a white cloth lap pad. "Ready with the bucket ?” I plunged my cupped, lap-padded hand into Maria’s wide open abdominal cavity, elbow deep, making a long sweep in and out.

"Doctor, that is disgusting.” Lori cringed.

"I know, Lori, I know. Isn't being a surgeon glamorous? We need to get her cleaned out. Get the bucket over here”. As my full hand emerged, the white lap pad was no longer visible. It looked like a large brown soft snowball. With one quick motion, I cupped another large handful of blood-stained stool Maria's abdomen, sweeping it into the awaiting bucket. "Lori, another lap pad please. Keep them coming. I can only breath through my nose for so long." Maria was testing me. It was only the beginning.

Maria had come into the emergency room two hours earlier She was in septic shock, caused, we would discover, by a life-threatening infection in her abdomen. She had been having abdominal pain for the last week but had no one to complain to, The trouble moving her bowels had been going on for several months. Finally, the pain got so bad, she called 911.

Maria was an attractive, yet troubled, forty-six-year-old woman who had been mentally challenged since childhood. Despite her early hardships in life, she lived independently and held down a steady job in the emergency room at the hospital.

Because she was different as a child, her teen years were difficult. Her twenties were made even harsher when the diagnosis of schizophrenia came along. In spite of all the difficulties, she always had a smile on her face and was a pleasure to be aroung. Now, Maria was in the operating room facing her most difficult challenge: staying alive.

More pads please. There is a lot of shit to clean out in here.” It was one of the worst-contaminated abdomens I had ever had my hands in, and I have had my hands in plenty of shit. Maria had a perforation in her distal colon. The large hole had created a wide-open window for stool to leak through, contaminating the rest of her abdominal organs. The infection was taking over her entire body. As I continued to dig through the mess with my is feeling for the hole, I felt something hard deep in her pelvis. "What is this?” I washed away the area with some saline solution so I could get a better look. "This feels like a cancer." I continued to wash. "It is a cancer, a large cancer invading her rectum.” I took a few quick breaths through my nose. I quickly reached up to feel the surface of her liver. "Damn. She has a hard mass on the surface of her liver as well. Probably a metastasis. This sucks."

"Can it get any worse for this woman?” Lori continued to wipe off every instrument I handed her.

"Most likely, Maria will never wake up. She will probably die within forty-eight hours, no matter what I do here. If by the grace of God she does wake up, and survives, then I will be forced to give her more bad news. Stage four rectal cancer.” I could hear the conversation.

Maria, you were near death's door from a severe infection in your abdomen. You fought death off bravely and after weeks in the hospital, you beat the odds. You should have even made it off the operating room table. Unfortunately, during the operation, discovered that you have advanced rectal cancer, with metastasis to the liver. I did manage to remove most of it, but I a permanent colostomy bag. Once you recover from the surgery, you will need to go through months of intensive treatment for the cancer. The treatment will be rough, cause you to get sick, and lose your hair. It may slow the disease down but will not eliminate it. In the end, the cancer will kill you.

"Lori, how cruel can life be?” I started to remove the segment of rectum with the cancer in it. It was not budging. "How much more can you ask a person to take?” I could see that Maria’s blood pressure was dropping. "If I were her, I would not want to wake up from this nightmare."

Maria's rectal cancer had gone undetected for months. It grew insidiously inside her to a point where it completely obstructed her colon, causing stool to back up for weeks. Her colon wall ultimately succumbed to the continued pressure and blew on like an overinflated inner tube, spewing stool in all directìons. Her pain must have been unbearable just before she got to the hospital - she had a perforated colon, had an obstructing rectal cancer, was in septic shock, and had an abdomen full of stool. Just one of these critical illnesses alone is lethal enough to kill any healthy individual. Imagine presenting with all four.

I cleaned out Marias abdomen as best I could and removed what I could see of the cancerous segment of rectum. I managed to dangerously low levels. While the infection in her abdomen was trying to kill her, the machines and drugs at my disposal were keeping her alive. Most patients this critically ill never wake up. If they do, they are usually a shell of themselves. Most are lucky to live beyond a few days after the initial insult. Maria was lucky to live beyond a few days after the initial insult. Maria was maxed out on life support, yet her heart kept beating. Her kidneys were shutting down, yet her heart kept beating. Her lungs were filling up with fluid, yet her heart kept beating. Her brain was in an infection-induced coma, yet here heart kept beating. The infection in her abdomen had a death grip on her, yet her heart kept beating. Despite all the antibiotics, every week I would reoperate on Maria to drain a newly formed pocket of pus. After every trip to the operating room, Maria's heart kept breathing.

"Nurse, what is new with our patient today?” I walked into Maria's I.C.U. room. It was day thirteen of her near-death experience.

"Seizures,” her nurse replied. "Today, we have seizures.” Maria had started seizing early that morning. "Look, see her arm twitching like that? It was a lot worse earlier.”

"Just great." I did not want to hear any more bad news on a woman who should have died twelve days ago. "Donna, I'm a general surgeon. What the hell am I going to do with seizures? Please, let's get a neurologist involved.” Maria's C.T. scan showed another abscess in her abdomen, below her liver. She had been having high fevers for two days, and this was the source. "I have to take her back to the operating room to drain another abscess. Donna looked at me with a "You have to be kidding me" expression on her face.

This woman has been in a coma for almost two weeks and is now having seizures. Do you really need to operate on her again?” We were all under a lot of stress.

"Don't blame me. I have no choice. We’ve come this far, and she is still alive. I have to keep trying.” I dreaded going back inside Maria’s abdomen. "Has her brother been in to see her?”

"No Dr.Ruggieri. He has not been around. I don't think he can deal with all the tubes, ventilator, and sickness in this place.”

Maria’s third operation went as well as expected. I was able to drain a large pocket of pus beneath her liver without damaging her intestine. Recurrent intra-abdominal abscesses in Maria were to be expected, given the contamination she had at the time of her initial operation. All I could do was drain them as they formed, as long her heart could stand the surgery. At this point, the only thing Maria had in her favor was her strong beating heart.

Over the next several days, the seizures dissipated and Maria's fevers disappeared. From my standpoint, she was on autopilot. Medically, everything was being done to buy her body time to heal. The only thing I did not know was whether she would have a normal mind when she woke up.

By the third week, I could sense a turnaround in her physical condition. She had been improving in small increments up until this point, with normalizing blood pressure and kidney function. Now her lung function was weighing in. "Donna, what do you think about getting that breathing tube out soon?" I want the nurse's input on every one of my patients, especially when it comes to milestone decisions. Intensive care nurses are very tune with their patients and often know more about them than their doctors do. Deciding to pull Maria's breathing tube was going to be one of those milestone decisions. It was a big decision because if her lungs faltered, a decision would have to be made to put the breathing tube back in immediately. If it didn't go back in, Maria would die within five minutes. Her brother was not strong enough to make that decision yet, not strong enough to decide whether to let her go or keep her alive.

"I think she'll fly, Dr. Ruggieri. She is more awake today, more with-it mentally.” Donna was confident.

"I think you're right. She is definitely more alert this morning." Maria had been in a drug-induced coma for weeks. She also had been intentionally paralyzed while on the ventilator. I wanted it this way. When her mind did break through the haze, she hallucinated, grabbed at tubes, and was a danger to herself. Comatose and paralyzed: two states that make my job easier in the intensive care unit.

"Maria.” I spoke directly into her ear. "Squeeze my hand." She did. "Great. We are going to get the breathing tube out today so you can breathe on your own.” Her eyes looked at me. "Good," I said, standing up. "Donna, let's aim for this afternoon. Call respiratory and get this going.” Despite the progress, Maria was not out of danger yet. Even if the tube was successfully removed, Maria was still a candidate for pneumonia, blood clots, a pulmonary embolus, C. difficile colitis, and more infections. Any one of these hospital-acquired problems could set her back.

Once Maria's breathing tube was removed, she continued to amaze us all in her ability to survive. The next week brought more improvement in every one of her organ systems. By the fourth week in the I.C.U. Maria was fully back with the living, both mentally and physically, despite the hell her colon had dragged her through. Everyone involved in her care from the beginning glowed with joy to see her eating, walking (with assistance), and making some sense. When I walked into the I.C.U. on the twenty-sixth day, I felt like the proud parent of a newborn child.

"Dr. Ruggieri, when are you going to tell her?” Donna knew it was time.

"Today, It has to be today. I cannot keep it from her any longer." I was not looking forward to this. "She has

to know.” I walked up to Maria's door and stopped, trying to figure out how I was going to break the news to her.

"Hi, Dr. Ruggieri.” She saw me coming. "When am I going home?"

I sat down on her bed and placed my left hand on the sheets covering her thigh. I looked directly into her eyes. "Maria, I need to tell you something.” She stayed very still. "When you came into the hospital almost a month ago, you were very sick. There was a hole in your colon causing an infection, and I had to operate on you emergently. You have been in the I.C.U. almost a month.”

"What caused the hole, Dr. Ruggieri?”

I paused for a few seconds. "Maria, you had a blockage from a colon cancer that caused things to back up. I had to remove part of your colon and give you a colostomy.” There was just no other way to say it.

"A cancer?” She let her left hand pass over the sheets sheets covering her colostomy bag. "Did you get it all?”

"Maria. I removed what I could. You will need further treatment once you recover from all the surgery.” I was not sure if any of this registered because of the blank expression on her face. Several uncomfortable minutes passed. I was out of words and to wanted to leave the room. As I started toward the door, Maria spoke again.

"Dr. Ruggieri, thank you for saving my life." I stopped and was too embarrassed to turn around. I did not want Maria to see the wetness in my eyes.

"You are very welcome.” Maria's heart was still beating. Part of my heart was broken.

From the book "Confessions of a Surgeon” by Dr.Paul A.Ruggieri, M.D.

Chapter 8: Patients are the best teachers