Secret Messages

The other day a woman presented to the hospital with vague abdominal pain. It had been nagging at her for about a month, and she just felt that something was wrong and wanted to get checked out. The emergency room scanned her over, and decided that there was something to her pain, and so she was admitted. The admitting medical team concurred, and consulted the gastroenterology group. Everyone was in agreement – her story, her looks…it all pointed to her gallbladder.

The only thing was that ultrasound – which is usually the best test for the gallbladder – was completely normal. But her blood-work indicated some sort of pathology- perhaps the gallstones had already been expelled from the gallbladder and were now stuck downstream? An MRI was ordered to confirm, but it, too, was normal. Her labs continued to worsen, and her pain persisted, so a nuclear medicine test was ordered. These are very good at picking up an occult cholecystitis, or attack of the gallbladder – sadly, it was negative.

I say sadly because patients like to know what’s wrong with them. Even when we hunt for a diagnosis and it comes back something scary, there is a certain relief in at least knowing what the problem is. There is a degree of comfort to at least giving your enemy a face, even if it is an ugly one. Most patients who have abdominal pain get a CT scan at some point during their hospital stay – in all honesty, it is often the first thing ordered. But in this woman’s case, the testing was more discretionary, and rightfully so. But now, with all roads turning up empty, worsening labs, and continued pain, a CT was justified.

When a CT scan is performed, it collects hundreds of images in just a few seconds to compile the pictures we see. Oral contrast is ingested to illuminate the bowel, and intravenous contrast is injected to illuminate the blood vessels and the highly vascular organs. When we ordered this particular CT, we asked the radiology tech to time the imaging to optimize our views of the liver and pancreas – the supposed region of interest – in the hopes that it might pick up any pathology. And it’s a good thing we did. The venous phase of the study showed the portal system was largely occluded. The liver actually has two systems of blood supply. It has an arterial supply (via the hepatic artery) which is analogous to every other organ in the body. But it also has what is known as the portal system. This is the network of veins which drain the bowels and bring their contents to the liver for processing. This is actually the major source of the liver’s blood. The clot within the portal system was so extensive that it had managed to kill the central portion of the right half of her liver. She wasn’t sick from a simple gallstone – she was sick because a major blood clot was killing off her liver.

She needs to have her blood thinned right away. And she’ll need that for about six months or until the clots dissolves. And we need to find out why this happened. There are really only two possibilities – either she has a disorder of her blood that causes her to make clots, or she has an occult malignancy, like lymphoma, that is causing her blood to behave this way. Either way, her life has been severely altered. It’s humbling to arrive at conclusions that are so far from where we start. Life’s messages are often hidden – we just need to keep searching to find them.

Pathways

A couple of weeks ago in church we heard the familiar tale of one of the most famous journeys ever undertaken. A long time ago, in a land far away from here, three wise men traveled a great distance to worship a child. The details of their trip are not recorded, but I can imagine that it was long, exhausting, and…indirect. I somehow doubt that their trip went too smoothly, and I am quite certain that it took them to a place – literally and figuratively – that they did not expect. For how could it not? It brought them to such a foreign land, with a radically different culture, where they experienced divine incarnation. Now how’s that for a road trip?

It’s interesting to think of our lives in this way - as a wondering journey, with some vague and abstract guide, leading us on to some foreign place. And what will we find? And how will it change us? Will we be so lucky as to encounter the divine along the way?

The great comfort of any journey is knowing that others have gone on before. Things are somehow less scary when we think we’re not alone, or at the least that the emotions and fears we’re experiencing are not totally unique. It’s comforting – don’t you think? – to pause and realize that others have done this before. A class in school, or a move, or a surgical residency…others have taken this path before. And made it. And the journey at the end of life – the pathway into death – I guess that’s the journey none of us really want to take. But as my friend’s father said at his wife’s funeral: how great the comfort is, knowing that our Lord has traveled there before.

I think about death often. I guess it’s because of the work I do, and that death is so prevalent around me. I think of my patients journeys into death, and what a wondering and twisted road it must have been – all the more twisted because somehow I became a part of it. I ended up being a part of their story, albeit at the end.

Today I told someone she was going to die. She is seventy-two, has five children, and yet I doubt that even one month ago she imagined she’d be sitting in that tiny hospital room she was sharing with someone else, with the curtain half-drawn and the TV next door still on, listening to some young guy like me tell her how mortal her condition is. Some journey. But then, in my mind…the knowledge and comfort that so many others – including our Lord! – have traveled this road before keeps me from breaking down. I pray that it brings us all peace, and that the journey – with all it’s indirection – leads us to encounter the divine.

Gut Check

The other day we were consulted to see a patient in whom they had discovered a pancreatic mass. This type of consult carries with it a mix of emotions. It usually means pancreatic cancer – a deadly diagnosis that often claims the life of its victim quite rapidly. Conversely, pancreatic surgery is some of the most challenging and rewarding operating there is. In a perfect world, we cure these individuals in fantastic manner. This patient was not the healthiest I’d ever seen. Pancreatic cancer normally strikes elderly, sickly folks, and this gentleman was no exception. He had smoked enough for two lifetimes, and it took its toll on his lungs and arteries. To even consider operating on a guy like this meant a meticulous pre-operative work-up. A work-up so involved, in fact, that we wanted to transfer him to a larger hospital because they had a greater ability to run more thorough tests. He was hesitant. He liked the hospital he was in – he felt comfortable, and it was close to his home so his wife could visit easily. She’d never be able to see me down town, he said in complete earnestness, even though it was hardly a fifteen-minute ride by car, bus, or train. It might as well have been half way across the country, to hear them talk. We argued gently. This was cancer, after all, and the bad kind – the kind that kills, and painfully, too. We weren’t even at the point to offer surgery. We just want to run some tests, and talk to some specialists….we just want to see if we can even do the surgery. Can’t we do it here? No; not well. We need you in a larger facility. He looked me in the eyes. I just have a bad feeling, he said quietly, his oxygen tubing snugly in his nose. Doctor…have you even had a feeling that something just wasn’t going to work out? Of course. Of course I do. Al the time. It’s my job to worry about the worst-case scenario, and to put my patients in the best possible position to survive should something catastrophic happen. Ok, he conceded, you’re right, I’ll go. But I just don’t think I’m going to make it. He went quietly. He thanked us and smiled. Two days later he was dead. I don’t know what happened, and nobody does. A heart attack, or a pulmonary embolus? He was in the hospital getting his myriad of tests and he just coded and died. Just like that. I guess he was right, this wasn’t going to work out for him. He knew something none of us did. He should have ignored us and just gone home. He should have – we all should have – listened to his gut.

Herniation

In the simplest sense, a hernia is when something goes where it shouldn’t. This requires a breakdown of the usual barriers in the body. Sometimes these barriers are simple, and sometimes they are quite elaborate. The consequences of a hernia, as you therefore might imagine, range from mildly irritating to rapidly fatal. As general surgeons we deal a lot with inguinal hernias, or hernias that arise in the groin area. This a place of natural weakness in the body – especially in males – and therefore has a predilection for herniation to occur. The bowel pushes through the floor in this region and can cause pain, or even a true obstruction of the gut. If there is enough pressure on the bowel it can become ischemic and die – off hand, I can think of one person who died under these circumstances. As trauma surgeons, we deal a lot with traumatically injured brains. When the brain is injured – from assault, or a car accident – blood forms inside the skull. When the condition worsens, there is too much pressure that then expels the brain downward through the base of the skull – the foramen magnum – on its way to the spinal column in a vain attempt to relieve the pressure. This kind of herniation is rapidly fatal. The other day I saw a hernia unlike any I have ever seen. This woman had her uterus removed several years ago. The remaining cuff – that is, the portion where the uterus opens into the back of the vagina – is either sutured or stapled. This particular woman had recently undergone chemotherapy, and as a result that cuff opened. As luck would have it, her intestines worked there way through that opening – she eviscerated her intestines through her vagina. By the time we got her to the operating room, that portion of her small bowel was dead and needed to be removed. It’s a miracle she didn’t die. It’s safe to say that none of us – neither me, nor the colo-rectal surgeon on call – had ever seen anything like this before. But we were all in agreement: nothing we had ever seen just looked so wrong and obviously in need of repair. The body has countless built-in defensive barriers, and when they fail the consequences are too-often catastrophic. Something things are just supposed to stay put. As we look towards the new year, let us assure the barriers in our own lives are solid, and that we don’t herniate where we’re not supposed to. Let us stay where we belong, wherever that is.

Between Two Worlds

The other night on call I was presented with a very sick patient. A woman in her early 70s had been admitted with abdominal pain. After a couple days of testing and retesting a CT scan of her abdomen ultimately revealed an ominous finding: pneumotosis colitis, or air in the walls of her colon. It likely meant that she had infracted part of her intestine and would need urgent and massive surgery. If she didn’t, we feared, she would die very quickly. Unfortunately what was required was a resection of whatever portions of her intestines were dead. Sometimes just a little, but often quite a lot – either way, it’s the type of operation that can kill you because it’s such a stress on your body. And so she had to make a choice. Spend a few quality hours with her family and likely be dead by morning, or take a chance at a massive operation which she might not survive. I hated pressuring her, but every moment we waited we risked more of her intestines dying. She looked at me with wide eyes – “I’m not ready to dye tonight.” A part of me wanted to tell her that that decision had likely already been made for us, but I resisted – she needed to find hope in the surgery I was offering. She signed the consent form. And so she was there, stuck between two worlds – so delicately in this world, and so close to entering the next – I could see her closing her eyes and wishing all this were a dream. But it was not. We put her to sleep and cut her open. With my scalpel I took long swipes over her abdomen revealing her damaged bowels. It wasn’t as bad as we thought – I’m haunted by the notion that she might have made it ‘till morning after all. I’ll never know. And so it is often in this work – we make decisions and live with them. But we get to live. Others, not always. The choices are ours; the consequences, theirs. All we can do is our best. And at this Christmas time I am reminded that long ago in Israel someone stood between two worlds, this one and the next. And then too decisions were made, decisions that ended in death. It is all so fragile. The family thanked us for our efforts. I pray we did right.

A View of the Forest

As I walked into the majestic church the bell was tolling. Steady, soft, ominous, it rang its monotone melody with a notable sense of purpose. As I scampered inside I was struck by how full the nave was. Sneaking into the very last pew on the left – for some reason the side I always sit on – I gazed upward. The gothic arches form a weave which, while architecturally similar to the underbelly of a great ship, is visually similar to the way the branches of tall trees interlace and form a canopy above a dense forest. The trickling beams of light from the stained glass often forms lasers of dense light, the way sunbeams pierce through leaves. On this day a few hundred of us faithful souls gathered in the nave of a gorgeous church to honor the life of a dear friend. As the incense rose upwards and the noonday sun intensified, little lasers of light dotted the congregation. I wonder, sometimes, what God thinks of us there, gathered in His church, honoring one of His servants. Sifting through the canopy of the church and the incense, His omnipresent vision piercing through, dancing among us like a firefly – momentarily intensifying and then shifting – He looks at all of us. Does He pity us for mourning something as petty as a human life? What does such a think amount to when compared to the eternal divine? Of what is my friend’s life when weighed against the resurrection? But no. Our God’s own son has gone before us into death, so He knows exactly what it is to lose a loved one. To feel the emptiness in our gut; to wonder incessantly about the prospect of eternal death. I utter softly: Dear God, have mercy on your servant Richard. Hasten your guardians to his side, and usher him into your courts; have mercy on his soul, and, if it be your will, I pray that he may spend this very day and all days forward with you in paradise. It becomes clear to me as the service continues, as the choir chants and the organ thunders…the business of building God’s kingdom on earth was entrusted not to angels or archangels, but rather to humans. To us. And so we must go onward, in the confidence of His love, to do His work while we still can. So go. Go to work. Let us make our time count.

On Call

There’s nothing quite like being on call. As I write this I am all alone in my little call room. As call rooms go it’s fairly comfortable – I have a bed, a bathroom, a TV, a desk with a computer…everything I need, really. Some calls are insanely busy – a hectic continuation of the day, with hardly time to swallow a drink of water before the morning arrives. Other calls are slow – a strange calm blankets the place. It’s not exactly the calm before the storm, but rather more like the eye of the storm – there is destruction swirling all around, which inevitably will blow my way. There are two aspects to call that I’ve never gotten completely used to. The first is the waiting. The pager will eventually go off, or the phone will surely ring. The door will knock. Someone will need something. When? Soon. At least, probably. Knock and the door shall be opened? Sort of, only I’m the one opening it (which may be very anticlimactic for some!). People ask questions of me – all sorts of questions, all day and night long – because they need to. Otherwise I wouldn’t need to be here. I remind myself that it’s an honor. The second is the loneliness. As a surgical resident, like it or not – and it turns out – I’m alone quite a lot. I don’t necessarily mind it, I guess. I can think, write, catch up on things…all alone. I’m getting pretty good at it, though something tells me I’m being prepared for something. I’m haunted by an old man who worked at a little restaurant near where I went to grad school. I went in late one night for a dinner, and while I normally went in with my classmates this evening I was by myself. He noticed this and made a comment about how I was alone – “but you’re supposed to be alone, I think,” he added. It struck me as an odd thing to say – perhaps he knew something. And so what will this call bring?