October 21st, 2003

White Coat

Two days in a row, even...or not.

It was going to be a boring day, O Best Beloved, yesterday was. The other kids took all the surgeries except for a PEG placement (I'm tired of watching big surgeries; they can have 'em) so I watched that, got to help snag the tube (go me for being helpful), and then did my two notes and sat around for a long time. Read some, dicked around on the Internet, and then suddenly my pager went off. Oh no, thinks I, I'm in trouble for some reason. So I ran and returned the page.
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.

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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.
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