I got the call from the ER because I was the “no-doc” surgeon, meaning I was the guy to call when a patient showed up needing a surgeon, and who had no primary care doc to direct the referral. Usually it meant trouble. A drunk who smashed his car and himself, possibly others. Stab-wound, gun-shot. People who don’t have their own doctors include more than those down on their luck; not all of them are nice. So when the ER doc calls and starts with “You’re the no-doc surgeon, right?” it raises hackles.
“Got an acute abdomen down here. Older lady, goes to Seattle for her care, comes in looking real bad.” Jesus, I’m thinking. We’re not good enough here for her elective care, but when the shit hits the fan, she takes a shot at anyone? Little did I know. About the shit, I mean.
Gotta admit, it’s annoying. Turns out this lady had had innumberable orthopedic operations for horrible arthritis. New joints, fusions. Infections, removal of joints. So why not call her docs in Seattle, if they’re so great? Such were my thoughts, having to leave an office full of patients and head to the hospital.
She was, indeed, sick as hell. Low blood pressure, rapid pulse, flushed, feverish, not entirely coherent. And her belly felt like stone: a rigid abdomen is pretty much a sine qua non of something real bad going on. No need for a lot of fancy xrays: check her cardiogram, blood work, call the OR, fill her back up with lots of IV fluids, cover her with antibiotics, get her upstairs. At her side, holding her hand, looking worried, her husband turned to me and asked “Is she going to be ok, Doc?” What an interesting thing: they chose their doctors carefully, so it would seem, bypassing us for those in Seattle. But now I’m “Doc” and instantly trusted to save her life. But that’s not my point. It is interesting, however.
A simple abdominal xray had already been done, and it showed “free air,” meaning air in the belly outside of the confines of the stomach or intestine, where it ought to have been. Perforation, of something. Usually, there’s no point in trying in advance to figure out the source: surgery is needed, no matter what. Sometimes there are clues from the history or physical exam: history of heartburn, indigestion, taking antacids, more tenderness in the upper abdomen, all suggest ulcer, for example. Nothing of that sort here. Because of chronic pain from her arthritis and many failed operations, she took high doses of narcotics, and was always constipated. Hadn’t had a bowel movement in several days. Well, actually, she had; it’s just that it all went inside.
The adult colon, if stretched out, is usually four or five feet long. In situ,which sounds, appropriately enough, like “inside you,” it’s like an inverted horseshoe, starting in the right lower abdomen at the end of the small intestine, heading up the right side toward the liver, turning to your left and crossing under the stomach, making a U-turn at the spleen, then heading south along the left side toward the pelvis, where it makes a corkscrew shape into the rectum. It can be pretty capacious, as Sally’s most certainly had been, until it emptied itself.
Pretty rare and highly deadly as a cause of colon rupture is a thing called stercoral perforation. It means a hard piece of feces has rubbed its way right through the bowel (nearly always at the south end of the colon); a seriously bad thing. Opening Sally’s abdomen, I encountered more stool than I could ever have imagined, spread everywhere: there were several enormous (what else is there to call them, really) turds, hard as rock, maybe a dozen. Swimming in no less than a gallon of liquid stool. Owners of motor homes who’ve had accidents with sewer hoses may have a vague idea…
The smell was astounding. The entire crew in the OR was bug-eyed. No one had ever seen anything like it, nor sensed it with pretty much all five. I filled a couple of big pans as I scooped out the solid stuff with my hands, then suctioned quarts more. (Despite the gloves, and vigorous washing many times after, my hands smelled like stool for days.) This was really bad: a huge bacterial load in an older woman who’d been in shock, portends a grim outcome. But she was hanging in there, having been properly resuscitated and maintained. Fast surgery is not always best per se, but sometimes it matters: the less anesthesia the better when a person is really sick. It’s impossible safely to close such a hole; a colostomy is mandatory, getting the damaged colon out of the abdomen, letting bowel movements happen into a bag until such time as the patient is recovered and suitable for reoperation to hook things back up. So that’s what I did, after irrigating the belly with about 10 liters of saline, followed by a diluted solution of bacteriocidal agent (povidone, if you care.) And closing with big “retention sutures,” big and widely-spaced: not pretty, but protecting against the wound falling apart which is highly likely in such circumstances as these. Closing the skin would be asking for major infection.
The family was gathered in the waiting area, and listened silently and tearfully as I told them what I’d found and what we were up against. The odds were greatly against us, but there were no signs that we couldn’t win, and we’d be doing everything we could. Expect a long stay in intensive care, under the best of circumstances.
Sally, it turns out, is an amazing woman, and became one of my favorites and a life-long patient. She never, as we like to say, turned a hair. (Where-ever the hell that comes from, it’s an expression all doctors use for someone who makes an entirely unexpectedly smooth recovery.) At minimum, I’d told the family, expect several reoperations or procedures to drain abscesses, to tidy the wound. Plan on respiratory failure, maybe liver or kidney failure. Pneumonia. And this was the best-case scenario. Nada. She sailed. She was walking around on her kneeless legs in a day or two. I’m gonna take some credit here: thorough cleansing, quick operation, good postop management. But Sally, she’s incredible. Nothing holds her back. A will of the hardest diamond.
Her belly is another story, or maybe the same one: it hardened, too. After six months or so, when I figured it’d be safe to go back in to close her colostomy, I encountered adhesions like I’d never seen. She hated her colostomy, and really wanted to get rid of it. As I struggled my way through, I thought a dozen times that keeping the colostomy would be better than suffering the complications of injuring the rest of her bowel to get there. But I managed to unravel the mystery without great harm and hooked her back up. She was delighted.
Surgically speaking, her life wasn’t easy before she met me, and the struggle continued after. She had innumerable bowel obstructions, as she formed adhesions like they were money. Some went away without operating; some didn’t. Each time I operated on her, I thought it was the worst obstruction I’d ever dealt with; the hardest to unravel, the most dangerous to tackle. Finally, there was the ultimate, and I thought I might have killed her.
Sally had come in with another obstruction (we’re talking many years after we first met, by now.) As usual, I’d dragged my feet well beyond what I was taught in training (“never let the sun rise or set on a bowel obstruction,” is what they told us. The worry is that whatever is kinking off the bowel could be compromising circulation, leading eventually to perforation. But there are times for clinical judgment.) After a few days of sucking on a stomach tube and high-calorie IV feeding, she hadn’t improved, and had developed a low-grade fever. Drag the feet no more, doc. And as usual, it was hell in there. Just entering the abdominal cavity was a nightmare: bowel stuck everywhere, no recognizable separation planes. It’s one of the most challenging and frightening things a general surgeon does.
Long story short. After spending hours moving my way into and through the abdominal cavity, and having nicked into the bowel several times (“inadvertent enterotomy,” we used to call that in training, at D and C conference (by all means, read my book to find out more)). My professor hated the term “inadvertent.” Have a suction device where you’re working: it means you expected it, he’d say. Good one.), I finally encountered the bowel that wouldn’t budge. A loop of small intestine was plastered into her pelvis, fat as a salami, but thin and fragile as the wet toilet paper she’d have used the day I met her, if things had been different. Having switched all her care to my clinic, she had a new doc (excellent guy. My own doc) who had her on a new regimen for her constipation. Unfortunately, all the fiber she’d eaten for the past days had congealed in that one loop of small bowel, and it was going nowhere. I simply didn’t think I could get it out of there without irreparably damaging the bowel, and, if I did so without the ability to work my way beyond it, and given the general immobility of the rest of her swollen and thin and surgically damaged intestine, I could imagine an insoluble (like the fiber!) problem. So I bailed. I found a loop of small intestine above the blockage that was barely mobile enough to bring out, and made a loop ileostomy, hoping it was downstream enough (no way to tell, given the tanglements and adhesions) that it wouldn’t be a high-flow faucet. I told her husband in the waiting room that I wasn’t sure it would work, I thought she might leak from everywhere, and she might or might not be able to eat again. Having operated on her several times, by now he never questioned a thing I told him.
Longer story short. She couldn’t eat without flowing out her stoma like a river. I installed a special IV feeding line, and arranged for her to hook up at home, at night, so she could be up and around during the day. We waited for months. Eventually I took an xray by squirting dye through the south side of the loop: the fibrous obstruction had auto-digested, and the pipes were clear. Could I close the ileostomy? Was it possible to cut it loose from the abdominal wall, mobilize enough inches to work with, and safely close it and drop it inside? Would I try? Should I?
Yes yes, yes, and yes.
Sally called frequently over the next many years, came in often. Always wearing shorts, showing her scarred and stiff legs. Always trusting, always pleasant, often just wanting a laying on of the hands and a reassuring word. I knew and cared for her for years, until her recent death for unrelated reasons. Her husband was always with her, always telling me how they’d never have gotten along without me. No doc. What a day that was.
Sid Schwab is a retired surgeon and author of Cutting Remarks: Insights and Recollections of a Surgeon.
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