Shubi was down in the OR. An exciting and interesting new case had just come in, and did I want to go scrub in, as she remembered all I'd done was the PEG tube? Hell, yes. Met up with her.
Abby (not her real name) is 18. She has Crohn's disease, which is an inflammatory/auto-immune bowel disorder that goes from mouth to anus, basically. It can occur anywhere in the digestive tract. It causes little granulomas and big problems. And in this particular case, Abby was in the middle of a raging flare-up of her Crohn's. She was on high-dose corticosteroids to control the inflammation, but had come in with agonizing abdominal pain. We got an X-ray. Free air.
It goes like this, O Best Beloved. The abdomen is a closed cavity, encased in peritoneum. Through the abdomen runs the gut - the stomach, small intestine, and colon - each end of which is open to the air. So basically you have something like one of those tube balloons, where the air you swallow and the gas produced by intestinal bacteria should stay in the gut and the squishy internal organs should stay outside the gut. Free air on an X-ray means that air has moved from the gut to the visceral space. Which means that the bowel has perforated.
Consider for a moment the contents of the gut. Remember that the pH of the stomach is about 2.0, and that from there on, it is gradually alkalinized. Pancreatic enzymes, bile salts, and other things designed to break proteins, fats, and other normal body components down into their component little bits are added to the contents. Bacteria grow and flourish. All of this is securely walled off from body parts that don't need to be broken down into little bitty bits; areas where if bacteria grow they grow dangerously. Until there's a perforation.
Abby had a perforation. So off to the operating room we went, in short order, for an exploratory laparotomy. Wheeled her in. "You'll have to take out your earrings." We use electrocautery, and anything metal on the body surface can be a potential grounding point where you can get burned. "And my belly button ring?" Yes. "I already took out my tongue ring." And don't forget the cartilage piercing. "I have a toe ring, does it have to go?" Is it metal? Then yes.
And to make a long story short on Abby, we found a place low in the sigmoid colon where it might have perforated, but we weren't sure. So we gave her a colostomy for now - to let the lower colon rest - and tucked everything back in. Her bowel was so tender and fragile from the Crohn's and the corticosteroids that we left it black and blue in places after going over it so carefully to find the hole. It was four and a half hours later.
But Abby's surgery wasn't what I wanted to talk about. What I wanted to talk about was Abby. Please forgive me, O Best Beloved, if the things I say offend your sensitivities. My thoughts and realisations and perspectives yesterday were the cementing of the reasons why I will not be a surgeon. I will learn to suture and to deliver babies and maybe even to do endoscopy. But I will not be a surgeon.
I kept my hands behind my back and watched while they started an IV, got her to take her earrings and belly button rings and toe rings off. They got her to pull her hands out of the sleeves of her hospital gown. And then they hyperoxygenated her, did a rapid-sequence induction, and put her to sleep. Shoved a tube down her trachea and got her on the ventilator. Bang bang bang. Taped the tube and the NG (nasogastric) tube to her face, taped her eyelids shut, popped the blue foam goggles on over her eyes and taped them down. Just like that, her face disappeared. She was neither plain nor pretty to begin with; your average girl, with a bit of the rounded face that plagues the chronic corticosteroid taker. I put gloves on. We peeled off her hospital gown, leaving her in just her undies, scant cover that they were. Kim took one side of the G-string, I took the other, and we tugged them off, too, and there was Abby, all the little things that we take for granted in our modesty in everyday life gone. Naked and vulnerable and completely at our mercy on the table.
You have to strip them down completely, O Best Beloved, and you have to do a physical exam when you can. Clothing can get in the way of things like Foleys. And you can't help but notice, when you're looking at a human being, what they look like. And perhaps it was the fact that she shaves her pubes that contributed to the illusion, but it was right then that I felt the dehumanizing begin. She was an Abby-doll, her face something out of a bad science-fiction flick, all goggles and tubes and hardly anything human about it. An Abby-thing.
"Can I do the Foley?" I have to do Foleys, they're in my procedure book as something I have to do a certain number of. And K was the resident; one of the fellows really, and plenty experienced in these things. Sure. Why don't you go ahead and frog-leg her so we can do a rectal first, then I'll walk you through it. So I took the Abby-doll's legs, and I bent them out to the sides, and I put the soles of her feet together, and we put on new gloves. And we examined her rectum, and talked about the skin tag she has from the fistula that the Crohn's has given her. And we spread her labia and reviewed external female anatomy to see where we were going. And the nurse cracked a joke about checking for a piercing there too. An Abby-doll. An anatomy model. And Kim walked me through sterile gloving, and swabbing her urethral area down with Betadine, and inserting the Foley all the way to the hub, inflating the balloon and pulling back gently. And we drained the Abby-doll's bladder, a good chunk of it all over the table. And so we got some chux and put them under her to keep her bottom dry. Good doll.
They sent me to scrub, as K got out the Betadine to prep her abdomen. Dr. W, who knows my mother-in-law, was the surgeon on the case. I went out to scrub (Get your mask and glasses situated. Wash your hands with anti-bac soap, all the way to the elbows. Clean your nails under running water. Then get the sterile sponge. Fifteen strokes on the nails, ten on each side of each finger, ten on the palm, ten on the back of the hand, ten on each side of each arm all the way to the elbow. Repeat on the other arm. Rinse, carefully, fingers up and elbows down. Don't touch anything. Shake, but carefully, so you don't drip everywhere. Back into the OR, and I do mean back up) and gown and glove. Came back in in time to watch the completion of the transfiguration of girl to doll to tiny open space. They take sterile towels and lay them down in a square around the sterile field. Then they take a sheet of something like very thin Contac paper and spread it over the abdomen and the towels. It glues itself to the skin. Then they unfold a sterile field. This is a large blue sheet that covers the patient from head to toe - it goes over the anaesthesia bar so that the patient's head is free for them to work, and drapes over the edge of the table on all sides. There's a hole in the middle for the doctor to work, and they almost always seem to need it bigger.
And I stood there for a moment, staring down at a hole approximately one foot wide and eighteen inches long, at the plastic wrap that insulated skin from air from any real physical contact with it at all, the plastic wrap that would be the first thing they cut, and then the yellow-tinged flesh, scrubbed clean of all things Abby by Betadine. I thought about the catheter running from her bladder to a bottle by the anaesthesiologist, the fact that I knew this girl's body by sight, as intimately - if not more so - than she did herself, that I could not even remember the face of the girl wheeled into the operating room without looking behind the anaesthesiologist's drape, whether her hair was black or blonde or red. I thought about all these things, and then Dr. W stepped up to the table and she said "Okay to begin?" And we began.
Abby-the-doll, barren of sexuality despite the grotesquely sexual positioning of the frog-leg, clean-shaven, belly button ring removed. Abby, who came in 18 and in pain and left with half of her colon stapled at the top and the other half draining out her abdominal wall. Abby - I know more about the lay of clean-shaven labia, the alignment of urethra and vagina, her yeast infection, that blasted skin tag from the fistula, the dip and curve of her abdomen as it crosses liver and spleen and that horribly ulcerated bowel than I do about her family, her likes and dislikes - or even her blasted hair or eye colour. I don't know how tall she is, but I know she weighs 60 kilograms and qualifies for adult doses of hyperalimentation. I don't know if she has a boyfriend or a best friend, where she goes to college, or what she wants to be when she leaves my care, but I know that her small intestine is red and swollen and edematous, that there are three stitches in it where the steroids made it so fragile it split, that her belly button is pierced, that the colostomy we did is something less than pretty by a surgeon's eye.
And that, O Best Beloved, is something that is more than just discomfiting for me. It's almost blasphemous, anathema, to treat someone in such a limited fashion. And to see your patient for only a few moments a day, hardly long enough to learn anything about them at all...
I know surgeons have clinics, and long-term patients, and people they know as well as a family doctor. But so much of their time is in the OR...and the OR is such an alien world for me.
I was going to talk about today, O Best Beloved, in which I didn't scrub at all and followed the interns around all afternoon, but I need to read before bedtime if I don't want to look stupid in the morning. Dr. C will ask us about Wolfe-Parkinson-White syndrome. And my mind is exhausted by that story.