Cigarettes & Alcohol

No one was coming for his heart or his liver, and it was clear why. No sooner had we taken a scalpel to the skin over his abdomen…my attending starting down by the pubis while I started from up under the xiphoid…we met at the navel…we got through the even poorer protoplasm below it and entered into his peritoneum to find a belly full of ascites fluid. His bowels, thin, pale and filled with air and succus, bobbed up to the surface of the yellow fluid. I placed a suction device deep into his abdomen and watched as the fluid drained out, much like it would from a bathtub with the drain pulled. Liters were drained and what remained were the sad contents of his jaundiced abdomen. The now visible liver did not glisten as expected, and it certainly wasn’t its usual color. It was cobblestoned and knobby, cirrhotic, tortured by this man’s very close and very daily relationship with alcohol. No. We wouldn’t be touching that. Or his pancreas, which was nearly calcified through and through likely from several bouts of alcoholic pancreatitis. His blood vessels, conduits which should be smooth and elastic, were crunchy...hardened by his slavery to cigarettes. Attempts to cannulate them revealed rinds and rinds of yellow, cheesy, calcified atheroschlerotic plaque, filling in the lumen, obstructing blood flow. It was a wonder this man’s legs were getting any blood at all.

We were only there for his kidneys. Kidneys that were risky to take, having come from someone in such poor shape. Kidneys that someone in a nearby state desperately needed. Kidneys that this man’s wife had graciously signed the consent form to donate despite the grief she must have been feeling after loosing a husband who, just three weeks prior, had decided to give up both cigarettes and alcohol. A hypertensive hemorrhagic stroke robbed him of his chance to try out his new life. He was only 51.

Far too young if you ask me.

I will beat you every time

Disclaimer #1: This post is not for the squeamish. If your delicate sensibilities preclude your tolerance of frank references to saliva, mucous, vomit, bile, excrement, urine, blood, semen, pus, or any other bodily fluid for that matter, you may want to skip along to a more light-hearted post like this one or this one. I know, I know. You may THINK you want to challenge yourself just this once. But seriously. What follows is considered by many to be truly gross. As the t-shirt that my brother gifted me with a few years back reads: trust me, i’m a doctor.

Disclaimer #2: Do not mistake any of the satire below for a backhanded insult to my profession or any of my patients. I love what I do. But every job has its mundane or less-than-glamorous tasks. Every job. For a secretary, it might be filing. For a stay-at-home mom it might be laundry. For an accountant, it might be accounting. For me, well, the scenario below definitely constitutes one of the less-than-glamorous things I have to do in my profession. For the purposes of patient anonymity, details are changed slightly. Enjoy. (Though if you do, you’re sick.) (Or, alternatively, you're meant for a career in colorectal surgery.)

In a recent visit to Mamichki’s house to see my Dochechka who is recovering from a recent lumbar spine operation, I bumped into a good friend of hers. One who, through the years, I’ve become friends with. (For the purposes of this post, we’ll call him Mr. KnowItAll.) (Which, for the record, he normally isn’t. Well, not seriously at least.) Mr. KnowItAll had just brought over a sushi lunch. My timing couldn’t have been any more impeccable. Free lunch! Woo hoo! As we sat down to a smorgasbord of raw fish, Mr. KnowItAll skillfully managed to redirect the topic of discussion from Doch’s recovery to the topic of the worst smell ever. Seemed a bit random at the time, but it’ll all tie together in a sec. Apparently he thought himself the authority on the worst smell on earth. Now…he knows what I do. And he knows where I work. Surely he knew that I’d have a story or two about foul smells. As I looked at him skeptically, he assured me he could top any story I might dig out of my surgical archives. I was all ears.

Mr. KnowItAll had volunteered in the ER at a county hospital about ten years ago. (Formerly an aspiring medical student, apparently this was the incident that changed his mind about his career choice.) He got called into an exam room. One with four other volunteers, a resident, and an attending physician already in it. Along with the 500 lb female patient who’s nudity was feebly concealed behind the less than adequate paper napkin they provided patients to change into for the physical exam. There were no stirrups on the exam table and this patient needed a gynecologic exam. Two volunteers on the right. Two on the left. They lifted and spread her mammoth, weighty legs. Mr. KnowItAll was assigned the task of holding up a flashlight, so as to illuminate the field for the resident performing the exam. Apparently, the patient, as evidenced by the aromatics that flooded the room upon the uncrossing of her legs, had not bathed in quite some time. Upon hearing this, Mamichki set down her piece of salmon nigiri. I ended up eating it for her since poor Mamichki proceeded to lose her appetite. (What can I say, it takes a lot to gross me out. Exhibit A: See below.) So that was it. An unsavory vulva. Foul, sure, but…

“Childsplay!” I chortled. I didn’t know I could chortle, but turns out I can. And haughtily. “That’s weak.”

Mr. KnowItAll looked at me with fish eggs stuck to his lips and eyes that shouted: Bring It On.

“Are you sure?” I always ask this of my willing victims. He nodded. And continued to shovel fish into his mouth.

I dug into my mental cabinet of Grosser Than Gross stories. I got to the P file. And pulled out one of the Peri-Rectal Abscess cases. 51 year old, diabetic, corpulent, follicularly gifted man comes in to the ER complaining of fever, chills, and excruciating anal pain for the last few days. The ER doc calls a surgical consult. This is where I come in. I examine him. Look at his bloodwork. Look at the CT scan that the ER had obtained of his pelvis. And I determine that this guy needs to go to the OR. He had a peri-rectal abscess. (See Figure 1, the little blob on the right is a much smaller version of what this patient had.) (For those of you who don’t know what abscesses are, they are a localized collection of pus usually with surrounding swelling and inflammation. As for why people get them, that’s a whole chapter in and of itself. This is not that kind of blog.) (It’s a worse-than-that kind of blog, actually.)

Now. Abscesses are gross. They’re gross anywhere. On the arm, face, shoulder. Gross. But near the ass, they’re even grosser. They can track from the skin, up into the tissue planes right alongside the rectum for inches and inches, becoming huge pockets of purulence, sometimes fistulizing with the rectum. AKA connecting with the rectum. Which means…yes, shit meets pus. Now that’s the kind of mingling you don’t want going on at your party. And that’s what this guy had. In his bum. We take him to the OR for an incision and drainage, the treatment for an abscess. I don a face mask, shoe protectors, an impermeable gown, two pairs of sterile gloves. The anesthesiologist places the patient under general anesthesia. Prep. Drape. Scalpel. In one swift movement, I incise the abscess. And proceed to get showered. Bathed, if you will.

With projectile.
Shitty.
Pus.

Or purulent shit. (Depending on how you want to look at it.) Either way, a torrent of frothy, feculent ass frappuccino. (This explains why I don’t drink frappuccinos.) (This also explains why I wear impermeable gowns.) And the smell! Oh the smell! Imagine rotting flesh being eaten by a vulture whose stomach contents are then pumped out, fried in a skillet with a pat of butter, eaten and then shit out the other end. Then multiply what that must smell like by 14.3. (Just a rough estimate of the caliber of stench we’re talkin’ about here.) In an attempt to be helpful, the circulating OR nurse put some peppermint oil on my face mask near my nose. But that only conjured the virtual olfactory equivalent of peppermint flavored ass gum. Which, call me crazy, I don’t think would market well.

Upon finishing my account, I looked up at Mr. KnowItAll. I think he actually gagged at one point. He’d certainly stopped eating long ago. Then, silently, he threw both his hands up in sweet, sweet surrender.

And that’s how I got lots and lots of free sushi all to myself.

Don’t challenge me to a grosser than gross game. Just don’t.

(I warned you.)

A shiny almost-new liver…

...someone got one last night. A forty-
something year old liver. From a forty-
something year old man who collapsed inexplicably at home. He was rushed to an area hospital, but the point of irreversible damage had been reached. He’d ruptured an aneurysm in one of the blood vessels of his brain. He was pronounced brain dead by two independent neurologists. His family came to a consensus, one that I’m sure was difficult, to donate his organs.

This is where I come in. About four times a month, I take a 24 hour shift of call for a group of transplant surgeons…I basically carry my pager around in anticipation of a call from one of the surgeons who needs an assisting surgeon to help “procure” organs should a donor come up. Two sets of hands are needed to procure livers, kidneys and pancreases. So I am the second set of hands, the assisting surgeon. I take these calls for a number of reasons. One. The two-year research hiatus from my surgery residency that I started in July doesn’t include the usual hustle and bustle of hours on end in the operating room. It involves lots of reading, lots of “researching,” lots of data collection, lots of writing, and only some interaction with patients (to the extent that I need to recruit them into clinical trials). But no operating. So as not to get OR-sick (like homesickness…well...kinda) I decided to do this work with the transplant surgeons. Two. It’s extra pay. If there is anything that most people don’t know about medical education…it’s that it’s expensive. I’m in more debt than I care to acknowledge. And if there’s anything that most people don’t know about surgical residency, it’s that it doesn’t pay well. So the extra money helps. Three. It’s interesting. I do not aspire to be a transplant surgeon when I grow up to be a full on, board certified, grade A beef surgeon. (Why, is a whole other story.) However, the idea that organs can be removed from one person and placed into another is something that will never cease to amaze me. Four. It holds a near and dear place in my heart. The Brit’s sister and father both died untimely deaths and both were organ donors. This all happened well before I started dating The Brit, and yet, I feel like they are among us, in the living, in a way. Strange, perhaps. And yet, strangely true.

It’s a bizarrely sublime thing, transplant surgery. Sublime because it gives people a second chance…diabetics with such horrifically far gone disease that their kidneys have failed, recovering alcoholics whose livers have been exhausted, countless others with countless other diseases. Second chances. A beautiful concept. And yet bizarre…because it’s incredibly morbid. Survival of one relies upon the death of another. It’s the juxtaposition of loss and gain, bad luck and good luck, death and life, sadness and overwhelming joy. It forces the collision of two worlds (that of the donor and the recipient) that would have likely otherwise never intercepted.

Actually, it forces the collision of a lot more than just two worlds. One donor tends to provide organs to multiple recipients. And the production that’s involved before the “match” involves a whole cast of behind-the-scenes individuals. On the donor side, there’s the physician who calls the transplant network who sends out the transplant coordinator. Often perceived as the “vultures” that hover around the “almost dead” in our ICU’s, these people often get the hard end of the deal. They’re just doing their job, but to the friends and family members of the potential donor it’s appalling what they’re asking…imagine your brother’s just been hit by a car and 24 hours later he’s pronounced brain dead and some person you’ve never met quietly approaches you with a card asking you to consider giving away his body parts. You can see how one might think that person an insensitive, intrusive vulture. But time, as the potential recipient knows, is of the essence. For the family of the donor, it’s never a good time. For the recipient, there’s never a better a time. On the recipient side there’s the physicians and nurses and social workers providing care for that person until they are transplanted, IF they are lucky enough to get transplanted. That brings us to the list, and all the people that go into making the list of who deserves which organ and how urgently. Toughy. Glad that’s not my job. I just show up when the powers that be have found that the blood types and body types (size does matter) between unfortunate person A and fortunate person deserving of second chance B are compatible. I show up at the hospital and there is a van waiting to take me and the other surgeon to whichever hospital the donor is located. If the donor is close, we drive. If not, we fly. We travel with all that we need…our special surgical instruments and catheters, the “coolers” in which we plan to bring each organ back, cold preservation fluid. It’s a big production.

Now for the operation. The procurement of the organs. The “harvest” as some casually refer to it (though, truthfully, that sounds a bit too agricultural for me). As the donor was wheeled into the OR last night, I took a good look, as I always do, at my patient. Looking past the tangle of life-sustaining IV’s, catheters, and endotracheal tube, I saw an otherwise normal looking 40-something year old man. But, poor guy, he wasn’t normal. Heart beating. Lungs oxygenating his blood, ventilating off the carbon dioxide (with the help of the ventilator). Kidneys making urine, which was spilling out of a catheter into a collection bag. But no “life.” Not a whiff of sedating drugs in his system and he was completely nonresponsive. Pupils fixed, dilated. No motor responses. No reflexes. No independent respiratory drive. For as many times as I’ve assisted in a procurement, the bizarreness of operating on a “patient” like this never seems to pale for me. To me, a “patient” is a person who I’m treating in some way, caring for, helping, healing. (Isn’t that what we all go into medicine to do? “Help” people?) Big picture, sure, we’re helping someone, probably many someones, with his organs. But zoom in on the picture, in that OR last night, and we were hardly “treating” this 40 something year old guy. Nothing, except maybe a time traveling machine, could help him now. And perhaps that’s how we justify removing his organs. And remove them we did. Patient prepped and draped, Dr. HG and I stood down by the abdomen while two heart surgeons, who’d flown in from Washington State, stood up by the chest. They made their incision first, down the middle of the chest, and we connected the top of our midline abdominal incision with the bottom of their sternal incision. Sternum sawed open. Retractors in. And there…full visibility of all that is normally tucked away under skin and bone. It’s anatomy more beautiful than DaVinci was ever able to capture in all of his pencil drawings. The reasons I became a surgeon are many, but anatomy is certainly up there. The heart surgeons went about their business of getting ready to take the heart, while we went about the business of taking the liver and kidneys. Lots of careful dissection. Identification of important structures. Catheters into the aorta and the inferior mesenteric vein. Clamp. Clamp. Preservation fluid is run through the catheters to flush the liver and kidneys out (numerous reasons for the preservation fluid, one of which is to remove the blood which would clot). Liver out. Kidneys out. Each into their own little basin with icy preservation fluid. Dr. HG steps away from the operating table to a separate back table where he readies the organs for their respective destinations. I am left with the patient, who by now is heartless, liverless and kidneyless. All monitors are off. The anesthesiologist is gone. It is an eerily silent moment in the operation. And I still have work to do. In the bothersome quiet, I dissect out the iliac arteries and veins (they are used as “extensions” for when the liver is sewn into the recipient, as sometimes, the vessels going into and out of the donated liver aren’t quite long enough). The vessels go in their own container of preservation fluid. And then, with two long sutures, I close the incision. Drapes off. Except for the incision, the slight concavity in his abdomen, and the silent monitors, not much looked different. But it was. Much different.

When I got home last night, I looked up the American Heritage Dictionary definition of patient:

pa·tient n. 1. One who receives medical attention, care, or treatment. 2. Linguistics. A noun or noun phrase identifying one that is acted upon or undergoes an action. Also called goal. 3. Archaic. One who suffers.

Our donor did suffer an untimely death. A ruptured cerebral artery aneurysm…death was his unfortunate fate, with or without his organs. Perhaps his family will suffer less knowing that he helped so many. I hope so. Now begins the afterlife.