It's 3 O'clock in the morning. I am "on call" for emergency general surgical cases. I awaken to the irritating sounds of a beeper sitting on my night-stand, as it has for the past 30 years of my career, controlling almost every aspect of my life. When I call the number displayed on the digital read-out, it is the hospital operator's familiar voice, connecting me with an anxiously waiting "house physician" in the emergency department of the hospital.
House physicians are fully trained and American Board of Surgery-certified surgeons who generally do not have a private practice of their own. They choose instead to practice their surgical profession by taking "call" in local hospitals, earning a fair hourly wage for their efforts. In the absence of surgical intern and resident trainees that commonly assume this role in larger teaching hospitals, these physicians are entrusted by the hospital to respond to the urgent surgical needs of hospitalized patients and triage new patients in the emergency room needing surgical expertise. In some ways, patients in non-teaching private hospitals obtain the benefits of "the system" because they can rely upon fully trained and often experienced professionals to attend to their urgent surgical needs. In contrast, larger teaching hospitals, whose "on call" systems I am very familiar with, having been a resident myself and having been the director of surgical teaching programs for the better part of my career, often have inexperienced first or second year residents, serve as "first responders" to the surgical needs of the hospitalized patients. The Achilles heel of the latter system is the quality of the hierarchical chain of command and its inherent time requirements. Precious minutes and hours may go by before the "attending surgeon" is notified of the ongoing surgical emergency. Depending on the quality of the training staff, the attending surgeon may choose to defer decision making to the in-house staff in deference to the learning experience inherent is such a decision.
I was the beneficiary of having a trusted "house physician" on call that particular night, whose skills and knowledge base I was fully familiar with, having reviewed his credential prior to hiring him for the job in my capacity as Director of Surgery. He informed me of the presence in the emergency room of an 80 year old nursing home patient, Joe W. The physician took it upon himself to do all the necessary preliminary tests, X-rays and physical assessments necessary for an elderly male patient who developed the sudden onset of severe abdominal pain, following his evening meal in the nursing home. All this took place, while I was resting comfortably in my warm bed at home. Now that he had made the correct diagnosis of an "acute abdomen" and even, anticipating the need for emergency surgery, had inserted a naso-gastric tube, bladder catheter and ordered blood from the blood-bank as required by protocol, he decided to summon me from home. He further informed me of the presence of "free air" on abdominal X-rays, the hallmark of a ruptured viscus (bowel), and his suspicions of a perforated ulcer in light of the sudden onset of pain in a patient who has been taking Ibuprofen on a regular basis for his chronic arthritis.
The need for emergency surgery was but a foregone conclusion. I managed get out of the confines of my warm bed in the middle of winter, leaving behind my wife and children whose only awareness of Old Joe W. was a tired husband and father who chose to go to bed more fatigued than usual at 9 P.M. the following night. They never even knew that I had been gone since 3 A.M. that morning. Just another typical day in the life of a surgeon.
Upon arriving to the emergency room and conferring with the house physician, I had agreed entirely with his assessment of the situation and commended him on his handling of the case, a gesture too often lacking by some of my learned surgical colleagues. I proceeded to meet Joe's anxious family who sat patiently in the waiting room. I informed them of the suspected diagnosis and the need for emergency surgery along with the dangers associated with such a serious operation in a man his age and associated multitude of medical problems. "Do your best doc" was their response, "we trust you". I never take such comments lightly. I consider it a privilege to be entrusted with the lives of loved ones like Joe, who appeared to be the last remaining patriarch of this family.
As I retreat to the O.R. dressing room in preparation for surgery, I can't help but feel a sense of humility, pride and obligation for being privileged to be there on that cold winter night. Would all of this, and the comfortable life I had enjoyed as a surgeon, have been possible without the perseverance of my parents and my upbringing? I owed it to Joe, and myself to do my very best in my efforts to save the life of this man in the twilight of his life. How often do I hear my colleagues lament of the waste of time and money to save the elderly. I tend to individualize my surgical decisions based on the circumstances. Joe W., despite his advanced age and life in the nursing home, had a meaningful life. He enjoyed visits from his family, and by all indications his family was genuinely concerned for his well-being and recovery. I reminisced about some painful decisions I faced with my own parents confined in a nursing home. The answer was clear in my mind. I will do my best to save Joe's life.
As I stood, dressed in surgical scrubs, just a foot away from this fully draped, anesthetized and prepped 80 year old man with and "acute abdomen", I noticed the O.R. clock. It was 3:50 A.M. "Incision", a verbal prompt to the nurses to document the start of surgery. I notice my heart and mind racing, as is often the case when I start surgery.
I hold the scalpel, like the violin bow I used to hold as a child and young adult many times before. Unlike the sound of music when I stroked the bow over the strings of my violin, my first scalpel stroke across the skin was met with blood and the sight of yellow adipose tissue, the sight of which I am so accustomed to. I look at the anesthesia monitor to check the oxygen saturation . My impression of the darker than usual blood, indicative of poor oxygenation, was not confirmed by a normal reading on the monitor. Comforted by this finding, I proceeded to make my scalpel strokes more deliberate. The "Linea Alba" , the white midline fascia we all posses, was encountered after just a few strokes, indicative of the emaciated state of 80 year old Joe because of the absence of a thick yellow fatty layer, common in younger patients. With the tip of my scalpel blade, I carefully incised the thin but fibrous Linea Alba. A dark membrane appears. Peritoneum, the holy grail of abdominal surgeons. Above, exists the world as we know it. Below, the mystery of a world few are privileged to know. The peritoneum was bulging, indicative of the "free air" evident on the X-rays in the emergency room. This air, usually absent, emanated from the hole in his bowel, the source of which is soon to be found and patched, not unlike a hole in a car's inner-tube. We hear the "swoosh" of foul-smelling gas escaping from the incision I made in the membranous peritoneum. Once I kept the exposed bowel out of harm's way, I proceed to enlarge the abdominal incision, just large enough to place a mechanical abdominal retractor, designed to keep the incision open, thus freeing the surgeons' hands to perform the more delicate work.
Once within the peritoneum I experience a feeling I often experience at this stage of an operation. I feel the sense of irrational guilt, as if transgressing a place for which punishment awaits. A place of taboos and the hidden confines of one's soul. I'm sure my surgical colleagues in other specialties may take issue with my interpretation of the location of one's soul. I can't help but feel a sense of pride for the privilege I had been blessed with.
I soon find myself surrounded elbow-deep by mal-odorous loops of slippery bowel, well beyond the thickness I would expect from normal bowel. Peritonitis is a term signifying contamination of the peritoneal cavity by substances and infectious materials, not normally present. Imagine placing an irritating substance into your eye and the resultant redness and inflammation that would ensue. I'm sure common sense would call for immediate irrigation of the toxic substance. In general surgery, there is a common saying; "The secret to pollution is dilution". Studies have confirmed that it takes many liters of sterile saline, to adequately irrigate and cleanse a contaminated peritoneal cavity. Although impossible to completely re-sterilize the peritoneal cavity, antibiotics and the self-healing properties of the peritoneum can safely be relied upon to finish the job of cleansing.
After dealing with the intense peritonitis I encountered in Joe, I proceeded to trace the source of the contamination to a typical place in the first part of the duodenum, just beyond the outlet of the stomach. The hole in the bowel was mushy, intensely inflamed and still spewing forth particles of food and golden bile. In such circumstances, it is prudent to "do no further harm". Instead of performing a risky bowel resection or permanent anti-ulcer operation, which may be appropriate in healthier younger patients, I chose to perform the quickest procedure I was taught to perform under similar circumstance. I stitched the hole closed and placed a patch of omentum (a fatty anatomical membrane ), not unlike gluing a rubber patch on a hole in an inner-tube.
"Good morning Joe, I'm Dr. Schreiber. You don't know me, but I am your surgeon and I operated upon you last night. How are you feeling?" "Ah-Huh", came a faint response. I chose to interpret the groan as: "Hi Dr. Schreiber, thank you for saving my life". After a bout of pneumonia and a urinary tract infection, Joe W. was ready to be transferred back to the dreary confines of his nursing home. I couldn't help but wonder. Did I do my 80 year old new friend Joe W. a favor by saving his life? Will he enjoy the winter of his remaining life, surrounded by loving family and friends?
My question was answered, loud and clear. Joe never said goodbye.
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