Saturday, December 13, 2008

Surgeon With a Pair

So what's the diagnosis?

Here are some clues. This patient is 104 years old and he came to the ER with a distended abdomen. He had a history of benign prostatic hypertrophy and had suffered before from urinary retention and sure enough, a foley catheter relieved both his abdominal distension and his pain. Of course his urine was infected and we started treatment and left the catheter in.

His granddaughter was with him and had medical power of attorney for him and she was great. Before I discharged him home I wanted to make sure he could keep fluids down, he had not been vomiting but I was out on a limb sending a 104 year old home with only a UA and some antibiotics. He didn't do so hot with his fluids so I ordered a non-contrasted scan of his belly. Good thing too.

The CT scan showed pneumoperitoneum, air in the belly, and this was accompanied by lots of free fluid as well. This, to me, was a death sentence, and I was very honest with the patient and his family and painted a grim picture of both treatment with surgery and the inevitable death without it. I offered "comfort measures" and hoped the patient and granddaughter would choose this as I felt his chance of surviving the surgery was nearly zero.

This old dude was a fighter, and very politely, he and his granddaughter said they wanted to try surgery.

That was a fun call to make at midnight to our surgeon on call, in fact, it was so fun that I prefaced my story with, "Dr. X this is Dr. Y and I am not joking with you... I have a 104 year old with a perforated bowel and he wants you to operate on him..." Silence, groan, "I'll be there."

As of today this 104 year old is extubated and doing well on the floor. I don't know if he will make it to discharge, but I do know that this is about the only country in the world where this surgery would have been performed. I hope he walks out that door and I'm glad that my instinct made me order that 'superfluous CT scan'.

So, can you see the free air under the right hemidiaphragm? Neither can I. Is that a stomach bubble or a bunch of free air? The retrospectoscope sees 20-20 and that's definitely free air. Props to the surgeon who took this dude to the OR, you sir, have big, brass balls.


  1. Free air under the right hemidiaphragm? Surely you mean 'left', or am I mixing it up again? (NOT something you want to do, especially in an exam - just ask my poor skills tutor: "The patient had a RIGHT-sided stroke, you idiot - look at his damn FACE!") When I saw it I thought it was free air at first glance, but when I've seen as many x-rays as you have that could probably have well been a gastric bubble.

    Would've LOVED to listen in to that call you made to the surgeon though - he must really hate you now :)

  2. Somewhere on the web a surgeon is writing a post.

    "You'll never guess what an Er Doc had me do......."

  3. Lol. Hey docs, I get these silly emails all the time, and THIS one reminded me of you:

    Two individuals proceeded towards the apex of a natural geologic protuberance, the purpose of their expedition being the procurement of a sample of fluid hydride of oxygen in a large vessel, the exact size of which was unspecified. One member of the team precipitously descended, sustaining severe damage to the upper cranial portion of his anatomical structure; Subsequently the second member of the team performed a self rotational translation oriented in the same direction taken by the first team member.

    In plain English, what really happened?

  4. "Jack and Jill went up the hill
    To fetch a pail of water...."

  5. i guess at 104 the choice was to wait to die or die while on the table asleep...i guess i would have taken the secon choice also..maybe he didn't make a choice about living but dying with out consciousness

  6. Takes good DNA and a fair amount of luck to make it to 104, these patients should be studied like moonrocks so we can learn their secrets. And that Aorta looks a little egg-shelly, I'd refer him for an echo and some other expensive studies, those Aortic Valves tend to leak a little at 200,000 miles...and whats his PSA anyway?

  7. angry medic,
    the classic finding on XR is free air under the right hemidiaphragm. i think in this case that we are NOT in fact seeing a stomach bubble, but free air. the stomach had a hole in it so this is all backward glancing navel gazing etc... pt still with us.

  8. Your patient was conceived in the back of the first model T to roll off the assembly line, and now he is texting his fellow centagenerians and about his popped gut. What a lifetime.

  9. pt walking. nasogastric tube out. fingers crossed.

  10. [cue music, sing-a-long!]

    I'm proud to be an American...

    [I love the word verifications here. Tonight, this comment was brought to you by:

    blesemi! blesemi mucho!]

  11. Woo! I'm so happy for him! (I've had some long lived-relatives on my Dad's side)

    You know what's sad though, in 82 years, when I'd be 104, if I rolled down to the 83rd Memorial Barack H. Obama Hospital, after filling out paperwork for 4 hours, I'd be told that, "In the opinion of the State" I lived a long enough life and would not be given the choice to have the surgery.


    I guess I better always have $10K in my back pocket to bribe a surgeon with a pair. =)

  12. The left hemidiaphragm is elevated with air beneath. You can actually see the fundus of the stomach within the air bubble.

    I know a couple of surgeons with the stones to operate on someone like this, particularly ones that trained in major trauma centers like New Orleans, Chicago or Los Angeles. They're used to bangers dying on the table.

  13. Well, I'm not a doctor, but I would say this is a classic example of what is wrong with American medicine. We are giving these expensive procedures to 100 year olds, yet millions of young people don't have basic health care, especially things that are preventative. We do not have the resources to be all things to all people. If you made it to 80, count your lucky stars and stop draining our health care. I would apply this to myself or my parents.

  14. I think it's cool they asked and listened. In social-healthcare Britain, they'd have refused the codger surgery, based on his age (you're 90 and your kidneys don't work? oh that's too bad, have a cookie while you make your will). In social-healthcare Canada, they probably wouldn't have asked and he'd have been strong-armed into a procedure he maybe didn't want.

    Word verification: tansm
    Oh if only, I could use a tan. It's a frickin' blizzard here.

  15. dear anonymous,

    couldn't disagree more. this man was fully functional at 104 and would have died within hours without the surgery.

    this case is not only a testament to the barely surviving best medical care in the world but a testament to personal responsibility. you would have it otherwise i guess, with committees deciding who would and would not get life saving treatment. this man had planned his retirement and saved been supremely responsible as he had an advanced directive and medical insurance. who are you to deny him this chance at another year on the planet? who is anyone to decide that? 'life, liberty, and the pursuit of happiness' and along with it the responsibility to plan accordingly.

    for every ten of these extremely aged patients that DO end up taking up their share of medical resources i can point you to thousands of twenty-somethings that decide to get behind the wheel after downing a fifth of vodka or smoking a rock and then get all mashed up in a crash. would you deny them care too? how about the child in the case that follows this one? he is going to take up much more than his 'fair share' of medical resources trying to win his battle with cancer, but his family did not plan for this and it will be at our expense.

    you make your argument, ostensibly, based on common sense and logic, but this is where your argument fails, for both would say that there are folks that 'deserve' to have us pick up the tab for their care and folks that don't. in the system we had prior to EMTALA this is exactly what happened. charity cases were commonly taken and happily and those that made poor decision after poor decision ultimately did not get 'everything' for free.

    you would make it all 'fair' by making all equally miserable. count me out.

  16. anonymous who thinks it is a waste of money to operate, you don't know how painful acid floating around in the peritoneal cavity is. the last two i did of these i considered simply palliative and one was 94. both survived as a nice touch.

    but mr anonymous could i suggest you curl up in your safe little house and go to work in your safe little office where you never have to see another human being crying out in pain due to a perf. your wonderful answers are great until you yourself put your hand on that abdomen.

  17. cholera joe,
    good call. not sure if i would see it if i was looking but the clinical picture was the thing that forced my hand. that and the fact that i loved this guy and his friends and wanted to be sure. would i have done the same for someone in a 'chronic vegetative state'? i don't know, it would have depended on the advanced directive and the willingness of the surgeon, but bongi makes a great point, even if the surgery was palliative, this man was in terrible pain and would either have had to be made nearly comatose on opiates in order to die comfortably or had his belly opened and fixed and washed out. the latter might even be a money-saver compared to three or four days intubated in the ICU on a dilaudid drip.

  18. hey frank,
    props for the moonrock analogy. right on.


  20. peaceful death at home 10 days after surgery.

  21. Damn.. Whatever be the cost incurred on the procedure.. at least he had the privilege of spending time with his loved ones before he passed away. You can't put a price tag on that.

  22. Very good collectivist logic, anonymous. The value of a human life is the degree to which that life can serve the interests of the state, and is measurable in terms of how much money it will cost the state to preserve that life. Each human is a drone in a social hive, and individual life is not sacred, Hell, it is dispensable as soon as the duly authorized beurocrat deems it non-productive. Humans are just meat machines, to be abandoned when repairing them costs more than replacing them. And, the ancient medical imperative to ease suffering and preserve life regardless of who the sufferer is because each life is inherently sacred? To Hell with that too. Corney old idea, and much too costly.

    God have mercy on us! We are becoming a colony of mechanistic, biological reductionistic monsters.