A humbling experience

Last wednesday night we got a call from the geriatrics team that one of their patients, and octogenarian, was admitted from clinic with abdominal pain and had a CT scan that showed one area of small bowel with pneumatosis (air in the bowel wall, usually an indication of dead bowel.) However, the person calling the consult said that the patient was stable, didn't have abdominal pain, and that the consult was a formality. They hadn't even ordered labs yet on the patient. We said we'd be by later in the evening to check her out as we were busy with other, seemingly more pressing consults.

Two hours later we got a frantic call from another resident on the team. Why hadn't we come by yet? Why weren't we rushing the patient to surgery? In the meantime, the medicine team got labs on the patient and they were stone cold normal. We came up to see the patient, a very pleasant woman who had traveled the world in her line of work as a diplomat who had retired to live in our communinity near her daughter. Her abdominal pain had been present for the last month, but now was gone and she was without abdominal pain and had a benign abdominal exam. The CT scan from earlier showed one area of compromised small bowel that was about 1 cm long. However, putting everything together and seeing the patient I decided that we operate on patients, not on radiological findings. The patient did not match up with her CT scan. I told the medicine team that we would keep a close eye on the patient, but that we didn't need to rush her to surgery.

I called my attending and ran the patient by him. He said he'd take a look at the CT scan from home. He called me back an hour later and said we should probably just take a look with a laparoscope to try to figure out if there was something bad going on inside. The patient and her daughter were understanding and agreeable to an operation. At laparoscopy, we saw a piece of compromised small bowel and converted to an open operation. We ended up finding a small piece of bowel that did appear to be necrotic, but it had not perforated and amazingly, the surrounding bowel and mesentary had done a great job of sealing off the compromised bowel. However, we ended up removing 100 cm of bowel that was inflamed. The patient now had about 120 cm of small bowel left, which is just about the minimum one can have and still be able to absorb food.

It was a humbling experience. I went to see the patient and felt like I had a good exam which was non-surgical and that meant that you don't operate. However, we ended up removing 100 cm of bowel. I'll never know if she would have done OK and healed her injury with or without surgery, but it was a humbling experience.

In other news, here is a great and pity article about universal health insurance by James Surowiecki from January 2010 in the New Yorker:

Fifth Wheel