“Musta been the ham sandwich,” he said as he leaned onto the operating table and belched a couple of times. We were halfway through an operation, and Doug, my partner, didn’t look all that good. I’d been in practice for all of a year, still greenish, and he, ten years my senior, was my guardian angel, my guide through the vagaries of the world of private practice, and the best surgeon I’d ever seen. Now, he was definitely off his game. We managed to get through the operation. Doug had an appendectomy teed up to follow, but instead of showing up, he’d gone to the ER, from which I got a call telling me he was down there being evaluated and requesting that I do his case.
I removed the appendix in time to take another ER call: Doug needed a surgical consult and requested me. Stone-faced, holding still stiffly, Doug was clearly in pain. X-rays didn’t show much. Lab work suggested pancreatitis. His abdomen was tender in the upper portion, which is where pancreatitis pain usually shows. So, for now, though he didn’t have the usual risk factors, I think it’s his pancreas, and I admitted him to the floor. “I know it’s not easy taking care of a partner,” Doug said, “so if you want to get someone else, I’ll understand. But there’s no one I’d rather have care for me than you.” That’s the thing: Doug and I had a great relationship: In the OR, we clicked like we’d been doing it forever. I loved him as an assistant; he loved me. But it would be daunting to take care of him.
Doug’s pain increased. Repeat films remained non-specific, but his white blood cell count was rising. Having no clear idea what was going on, I called another surgeon for moral support and scheduled surgery. I opened Doug up and found a twelve-inch segment of small intestine twisted around a single “guitar-string” adhesion. By far, the most common occur due to prior operations; they’re rare in virgin abdomens, like Doug’s. But he had one, and it killed a piece of bowel — or close enough to make me afraid to leave it in.
When doing his own operations, Doug had a thing about closing the mesentery after bowel resection. It’s like a curtain between the bowel and blood supply, and he sewed up both sides instead of just one. Sewing prevents a hole through which another intestine could slip, causing an obstruction. Nevertheless, most surgeons, myself included, sew only one side because the unsewn surface heals to smooth pretty fast. Figuring he’d be pleased, I did both sides, using his favorite suture, the old-fashioned chromic catgut, instead of the newer style I liked. (Foreshadowing: doctors should treat doctors as they’d treat any patient.)
“You cured me,” he said on awakening, wanting out of there immediately. Until he started to vomit a couple of days later. For brevity, let me say it was hell on earth. I was miserable: Doug wasn’t getting better, and I didn’t know why. I couldn’t sleep. I got second opinions. Then he started going nuts. It’s not rare: The combined effects of altered sleep, drugs, and stress, mean a certain number of patients will develop postop psychosis. At first, he was just mildly paranoid. He started coming up with bizarre diagnoses, convinced he had a horrible infection inside, and began to accuse me of deliberately withholding reoperation.
Early postop bowel obstruction happens sometimes; typically, it clears on its own. I hung in there as long as I could, with Doug getting more accusatory. Finally, I decided to re-operate. The surgeon I asked to assist didn’t agree, but I thought I was right for psychological and physical reasons. What I found was entirely unexpected: Everywhere I’d placed that chromic suture in his honor, he’d reacted with swelling and hardening of the tissues containing it. His bowel anastomosis had puckered into a tight kink, something I’d never seen before nor have since.
“Well,” the assistant said, “You were right. This would never have opened up.”
So I re-did it with my kind of suture. And before he woke up, I inserted a special catheter into a vein below Doug’s collarbone to allow high-calorie intravenous feedings because I feared he might not be eating for several more days. It took a few more days, during which I was a wreck. But Doug started eating and doing well. Finally, I removed the IV, planning discharge for the next morning. “Looks like we made it,” I said that morning, feeling elation, not felt for seemingly eons. And there it was: his entire right arm was swollen. Blood clot, no doubt from the IV I’d inserted. Doug’s had gone in easily, first shot, like driving a scooter into a tunnel; no reason to have clotted.
So which is it, I thought? Push Doug out the window, or jump myself? Now he needed anticoagulation; of course, I figured. As a result, he’d bleed somewhere, probably into his head. Or develop post-phlebitic syndrome — uncommon in the arm – unable to operate again. Write my obituary.
Well, he got better. No arm problems, no bowel problems. He brought me a bottle of wine one day; we never talked about his accusations. I did ask him if he thought the experience would change his attitude toward patients with problems. “Nope,” he said. “Let’s get to work.”
Footnote: I’ve never seen a description like Doug’s suture reaction anywhere else. This is why I suspect the writers of Grey’s Anatomy must have read my blog when they made an episode about it.
Sid Schwab is a retired surgeon who blogs at Surgeonsblog and is the author of Cutting Remarks: Insights and Recollections of a Surgeon.
