Saturday, July 21, 2007

dead bowel on a saturday morning

87 year old lady with a history of CABG, stroke, and peripheral vascular disease who came in two days ago with diarrhea, weakness, nothing too specific. I get called at 6:30 am today because she apparently decompensates overnight and now is intubated and on Levophed (a vasopressor). A CT was done which suggested the possibility of portal venous air. I show up and she's on 80mcg of levophed, has blue fingers, and a rigid, peritonitic abdomen. Her lactate is 13. Her pH is 7.20. She's cooked, experience tells me. Mortality for ischemic bowel remains around 70-85% even in the best of scenarios. And this lady is a disaster. The quintessential vasculopath. She has no chance. I know that. The nurses know it. The internist maybe knows it. But when I tell her daughter, the daughter who lives with her, cares for her, loves her, a daughter who can't imagine a life without her mother, well, she wants everything done. Even if she only has a 10% chance. Even if surgery will only likely increase her suffering. As young surgeon, I agree to explore her. We open in the midline. The subcutaneous fat barely bleeds, her vasculature so clamped down. Foul smelling acites spills into the field as I incise the peritoneum. And then the inevitable; blackened, necrotic small intestine pushes its way through the wound. The more I pull out, the worse it looks. Gangrenous bowel from ligament of trietz to terminal ileum. Likely superior mesenteric artery thrombosis. I look up, her pressure is 68/50, anesthesia frantically trying to push drugs, fluids, blood into her. Enough. Give me the #1 PDS. I close the skin only, like you would after a organ harvest on a cadaver. We take her back to the ICU. Morphine drip. Tell the daughter. She dies minutes after the family says goodbye. What did I do here today? Is this part of the job? To give family members the self satisfaction that "everything " was done? Maybe I should have refused. There's nothing to do.. Let your mom die in peace. The next case. But just you say no to some middle aged adult child crying, begging you to do something, anything to try and save their mom.

25 comments:

Bongi said...

this one was pretty cut and dried. i think you would have been more than reasonable to refuse. yet i don't think you made a mistake by giving the daughter what she wanted. maybe one could have stated the case better, but i don't know.

the difficult ones are where if you do nothing the patient will die, but if you do something the patient will probably die. and if you do nothing the patient will probably die, but if you do something the patient will die. and knowing the difference

Cathy said...

I just read everyone of your posts. I enjoyed them all!

buckeye surgeon said...

glad you enjoyed them cathy.

Sid Schwab said...

It's really difficult to refuse, but I can say I did everything I could to do so in such situations. In a case like that, as if it wasn't crystal clear already, the portal air is the clincher. Yet, hearing that, when the familiy still insists, saying no is pretty hard. I don't know the answer. In part it goes to what I was arguing in my ''solution" to the health care crisis: such futile care ought not be covered.

buckeye surgeon said...

Sid-
That's a good idea. These patients who linger hopelessly in ICU's for days or weeks, waiting for one more organ system to fail until it puts them over the edge represent a significant chunk of medical expenditures in America. Making people pay out of pocket for futile care would be an interesting way to convert full codes into DNR-CC's a lot sooner.

Bongi-
Great 2nd paragraph. It ought to be the prologue quote for the next Cameron edition.

Anonymous said...

Thank you for this blog. It confirms the diagnosis and treatment that my mother in law received here in Austria.

She is 87, and was admitted to the hospital at the insistance of my husband three days ago. Her GP had diagnosed her with a stomach flu and told her to drink a lot, but she just kept getting weaker and weaker and more and more dehydrated. She did not have severe abdominal pain, but was not eating or drinking. At the hospital, they diagnosed an infection, but were unable to locate it.

After 2 days, they decided to do exploratory surgery and discovered that her small and large intestines were black and dead. They closed her up and brought her into the wake-up room, where they are keeping her on high levels of pain meds and basically waiting for her life to end.

Buckeye Surgeon said...

Anon-
Im sorry about your motherinlaw.

Medical hypocrisy said...

Well I think it's pretty piss poor the regard "patients" are being held in these little surgeons blogs.
First and foremost lest we forget the oath to preserve life physicians ideally take beyond merely paying lip service to tradition.
The business of medicinal care and treatment is the business of people, not "next case."
These are human beings seeking help and should be treated with dignity, respect, and above all else compassion. If a persons individual case is beyond medical treatment than a physician with ANY humility should GLADLY exhaust ALL options.
Its this type of remote, distant, self-serving , condescending attitudes held by physicians that give them the reputation they typically have of being cold and detached. Did you attend medical school for the God damn money or to genuinely try to help people?
If humoring a womans desperate request to try to save her mother is a wasted effort in the perceptions of some here, regardless of the reality, then some here should consider a different field to work in.
Just remember, it can be ANY one of us under that God damn knife so, remember that next time you are inconvienced by a little humanity.

Buckeye Surgeon said...

"Medical hypocrisy"-
Your tone and choice of diction suggest an anger that derives from some sort of unfortunate personal experience. Either that or you're just trying to be a troll....

But surely you aren't trying to make the argument that surgeons should always operate on a patient no matter how hopeless the situation is?

Hmm. I just re-read your post. It actually makes no sense. Hard for me to respond accurately to incoherent thoughts....sorry.

Medical Hypocrisy said...

On the contrary, are you arguing a patient should be treated only when YOU arent inconvienced?
My tone and choice of diction is entirely irrelevent to the fact your condescending disregard for a patients humanity is disgustingly shallow.
Your God damn right Im suggesting and arguing you and all physicians should operate and treat even when the situation is "hopeless."
That's the problem here, who in the hell are you to arbitrarily determine the hopelessness of a condition with a patient WITHOUT first exhausting all possible treatment approaches?
Does your God complex interfere with your humanity to THAT extent?
Clearly it does your humility.
It should be mandatory in order to be licensed to practise any prospective physician be required to watch the film "The Doctor" with William Hurt. It wonderfully depicts the self-ingratiating smarmy arrogance and back slapping of a prick such as yourself...UNTIL the situation is reversed and he's under the knife.
As I said before, while you are making your ethically illegal fortunes playing God, just remember your own mortality and the fact it can easily be you being written about on some smartasses blog that was inconvienced on a saturday morning to try to save someones life. If you dont like dealing with families and their emotions at losing a loved one, get the hell out of the medical field because you certainly arent in it for the sole purpose of the preservation of life.
I wonder what the Ohio board of ethics would think about this blatant slap in the face to the hypocratic oath?

Buckeye Surgeon said...

Hypoc-
I really ought to delete but I think the contents of what you have written are so hilariously incoherent, so out of the realm of sanity that maybe it's better I leave them for everyone to ridicule.

If all I cared about was "making an ethically illegal fortune" then wouldn't I be advocating the exact opposite of what i actually aver; i.e. that I ought to operate no matter what? Because you see, if I don't operate, if i recommended palliative care measures, then I don't make as much as if i took the patient to the OR. Do you see how that works? Let me repeat. If I operate on a hopeless cause, I get paid no matter the outcome. If I use my brain and adhere to my sense of humanity and realize that operating on a lost cause will only lead to unnecessary pain and suffering for the patient, then I get small consult fee. So.... try to process these basic links of rationality before spewing forth more vituperations like "prick" and "smartass".

oldie said...

Sorry if I posted this twice. I am getting the hang of it I hope. That family was lucky. Didn't take long before she got her wings and flew out of her misery. Check this out -- a 39 year old -not the sharpest knife in the drawer but he is the love of my life and my whom I adopted when he was five -with similar health condition had one foot of intestine removed. Two months later he went in and was told the entire bowel was dead. Doc gave him 3 hours. Next day since he is up and calling out football plays they figure maybe they overlooked something. 3 hours long ago up. He agreed for them to do another look. Was told that it was worst than the day before. Gave him another 3 hours. Two weeks later because he just won't die they transfer him to a "Care" home under Hospice. Family decides they will do hospice at home. To weeks later he still won't die but the little green stuff is pushing through the stapled section down the middle of his stomach. Family seek a third opinion. Third opinion send him to specialty hospital. Doc operates and removes all dead intestines and gives him three hours -- he say "just not compatible with life". Two months later he is living in a convalescent home assisted by TPN and a "vacuum cleaner" awaiting a "number" by the specialty hospital to be evaluated for transplant. Weeks later at the assessment the verdict is "too thin; needs about 25 more pounds." "I will e asking our team to adjust your TPN to fatten you up and also physical therapy." Back to convalescent. No markable change in TPN or physical therapy. Spending more time transferred to nearby hospital and back and forth. Finally gets the nod from specialty hospital - the dream has come true! Not! Sent there because they are the experts in treating wounds - 13 massive wounds. He has the "worst case of malnutrition and MRSA they have ever seen!" Several needed wound vacs. Family had never been told of MRSA. Sores were all nicely covered when family visited him at convalescent and other hospital. He was in ICU and came out of that. Darn - he won't die! Family was told that if his blood pressure goes down again they will "not use any oppressors" Today, ten months later, he was told (not by the surgeon who was supposed to do that surgery or another kind of surgery) - don't know what hole he dropped in to because we never heard from him as followup or anything: ten months on TPN and praying for a colosomy or something something "there is nothing we can do; you are going to die!" You don't need to answer. Just needed to vent. oldie2@aol.com

ADiva2Die4 said...

I found this blog on a search for "dead bowel". I am a BSN and I recently transferred into the ICU. We had a patient present with this situation and had the same outcome you described.

First, I want to thank you for sharing your thoughts and experience. Second, I'd like to comment on Medical's comments. I agree that there are underlying issues from this person. It's very difficult for people who don't do what medical professionals do day in and day out to make such lofty judgements. If someone is in the medical profession just fo the money, then they are one of the most shallow unfeeling persons in the world. You cannot witness the pain and suffering by a patient as well as the emotional pain families and loved ones feel as someone becomes critically ill and not "feel" something yourself. Again, I don't think this person realizes the cases that don't get the care and attention they should because there is another case that has a poor prognosis taking up valuable resources. I do not and have never discounted human life, I think perhaps like you, we understand the suffering a person goes through when their body no longer is working.

Thank you for your blog. I will continue to return and visit your posts.

Anonymous said...

I just have to leave a note concerning this condition. My mother was misdiagnosed at age 47 with a ulcer etc and she had a dead bowel. Needless to say after a month in surgical critical care, she lived to have a temporary ilestomy. However, like the daughter, I would have told them to do anything at the time to keep her alive. I had a warm feeling she would live, but I knew the odds were slim. I had no idea about this condition until I witnessed it firsthand. I'm glad she got to a good hospital in time. I know she is lucky. God bless you all that may go through this.

Cindy Ross said...

Not sure if you received the first one, my question is: how long does it take for dead bowel symdrome to come on a patient, is it hours days or weeks. My sister just passed away the other night due to dead bowel syndrome, we initially took her in for BP very low, which caused her kidneys and liver to shut down. Can you tell me, please?

Buckeye Surgeon said...

Cindy-
It depends. Sometimes patients crash in a matter of 1-2 hours. Sometimes it's a slower process, over a day or two. A big factor is the underlying etiology of the ischemia. An embolus that lodges in the take off of the SMA will lead to faster deterioration than thrombosis of a lesser branch.

Kelly said...

My mom had uterine cancer back in the mid-80's. She has since has nearly all of her large intestine removed and as much of her small intestine as they can. Radiation damage. What is left is dying because the capillaries are no longer functioning. She asked her doctor what her options were once they were dead and he said she shouldn't worry about that yet. So, that worried me. Are there options? Once her intestines are dead, is there still hope or is there nothing left to do? She thinks they'll just shrivel up and be absorded by her body like her uterues was but it seems as though they need ot be removed. She is in her early 50's. Unfortunately she has the insides of a very sick 70-something.

Anonymous said...

My aunt just went thru an exploratory laparodomy and the surgery was a success. She had been having belly and back pain for a few days and she had been throwing up for several months. I begged her to go to the doctors and finally the pain was intolerable so I took her the the ER. after less than 24 hours the DR ordered a CT scan at around midnight on Friday. Saturday around 3pm i went up to the hospital after work. As soon as I walked into her room there was only her and several doctors and nurses. the doctor ordered another ct scan of her heart. the ct scan the day before was of her abdomen. after the ct scan was done the dr and surgeon came to talk with me and stated that her bowls and small intestine were dead and needed consent to do the surgery. They were willing to do the surgery on a woman with failed kidneys, 2 heart attacks and 2 strokes. She does dialysys 3 times per week for about 4 hours each day. She had a triple bypass as well. when the doctors rushed her down to surgery the surgeon came out and stated that the bowls and intestines are dead and they may find more dead organs, he was concernd about air pockets by the liver and stated that he may just have to close her back up and she not wake up after this. I was terrified. he stated that he would come out right away and let me know what happened. After about an hour i knew that he did the surgery. He saved 150 synometers of small intestine and a small piece of her stomach and attached them with out a colostomy or ostomy. her colon looked good. after about 2.5 hours she was out of surgery. When I went back and spoke with the cheif surgeon he stated that the surgery itself went well but there is a high rate of death after. It has been 5 days since the surgery and she is recovering better than expected. I believe that if there is a chance one should take it. Has she not signed the consent for sugery form she would be dead. I am so gratful for the surgeons that took the risk of surgery.

Anonymous said...

I found this blog as I was searching for information on the latest of my daughter's father's many health conditions. About three months ago he was diagnosed with angioimmunoblastic t-cell lymphoma. He has been in and out of the hospital with septic shock and sepsis since. My daughter is in charge of his medical treatment. Had I found this earlier I would have advised her against the surgery.

Exhausting all measures to keep someone alive is cruel and pointless. I cared for my dying mother for over two years while her husband insisted on keeping her circling the drain. It is not dignified, nor is it humane. No one should have to suffer such an existence.

To "Medical Hypocrisy- Perhaps you should take into consideration that one day YOU may be kept circling the drain for the sole purpose of making someone else feel they did all they could do.

Anonymous said...

My aunt, aged 57, has had a great deal of surgeries; Triple Bypass, Carotid artery bypass, Aortobifemoral bypass,and she has 8 stints. In July she went into the hospital with a hernia and they found a twisted bowel, a great deal of scar tissue and adhesions. It is now 20th September she has been readmitted to the hospital multiple times with what the doctors have simply stated as illeus. She has spent July-September either hooked up to an NP tube or vomiting ~5 times per hour. It amazes me that just last night a doctor suspects ischemia...it makes perfect sense. This last admission they found a physical obstruction just past the duodenum. Typically this would be a surgical move. I am quite aware that surgery should be avoided. However, my aunt has spent the last 3 months puking dwindling away slowly. This is a poor quality of life. She is ready for some action other than decompress and send home. The physical obstruction presents an opportunity for surgery to remove not only the blockage, but more adhesions and scar tissue. We realize that this is not only risky, but most likely will result in death as you describe. That is a risk that she is willing to run for something to be done as opposed to nothing while she slowly withers away, but sustained by tpn, fluids, electrolytes, blood units etc. We of course could refuse any treatment at all, but we feel that is no chance where surgery might provide, slim though it maybe, a chance for improved quality of life if she survives. If she goes she'll be loaded up on drugs and pain free. If we continue the current route it its prolonged pain and suffering. Would you in this case, if the table was turned upon you as a patient rather than a surgeon, choose the nothing route and painfully whither or take a stab at an improved quality of life (no matter how short that improvement might last)?

jacque said...

My 53 year old sister died 3 days ago. She went in to the hospital on Sunday with severe abdominal pain. After a very short time being there her heart stopped. It took 35 minutes to revive her but they got it back.. I live out of town I didn't get to the hospital to after this happened. By the time I got there she wasn't talking anymore she was out and they were headed for the surgery room with her to open a wrap did look at her intestines. The surgeon came back very quickly and said the blood flow is not get to the bowels. They left her open and did some kind of wrap on her because I get could not get intestines back i.. Monday all family members that is trying to get some response out of her and there was a little bit but nothing you can really jump up and down about. Tuesday a nurologist looked at her and her and said there was still brain activity. She was not a vegetable. although she had probably been dead since Sunday we told doctors to do everything they could. It might have been better to let her go. They took her into surgery opened her up and her lntestines were dead and also her colon was.dead. they sewed her up, brought her back into the room., turned off all the machines and she died. If I had to go through this again I do it the same. we have no regrets. If I can remember right she had 4 percent chance that she would recover. Since there was a chance we gave it everything we had until there was no chance.and all the family members feelgood about that.

Anonymous said...

@buckeye surgeon... do you still respond to posts? My father (58) is dying of a rare form of NHL. His largest tumor is in his stomach which has caused him chronic compications. He does not want heroic measures taken as he is quite aware of his prognosis. I, however, am desperate to find some information on what to expect if he has a blockage and no surgery is performed. He left to visit his brother 1500 miles from home earlier this week. He was just admitted last night for a blockage, they are treating with an NG tube to suction to reduce nausea. Can you please tell me what the likely outcome will be? Should I be ready to make travel plans? What questions should I be asking? Is it possible for this blockage to "unblock"? Thank you in advance.

Lee Armstrong said...

My mum died 13th of dec 2013. She went in for a an op to fix ulcers on her stomach. Keyhole. A simple op I was told. She then had another because there was a leak of some kind. They fixed that then a blockage in the artery that feeds blood to the small bowel thus gangrene formed. They had an experimental op to see if they could fix that problem. She died three days later. If anyone here are up to speed with this all I would like to know is could they be linked? We have been told it wasn't. By the way the last op she had the surgeon told us it would probably not work but he wanted to make sure he gave her every chance. She suffered for 2 days before I told them to make her comfortable wish is obviously killing me but she would of wanted to live. And if it had worked them two days would have meant nothing to her. Should surgeons give the patient every chance. Answer is yes pure and simple.

Linda Lidestri said...

I'm sitting bedside vigil with my cousin who has faced the facts and is in hospice due to this. She knew surgery was too much of a long shot and is bravely awaiting her end comfortably with family and friends. At 53, my message to everyone is STOP smoking, treat your body right. Watching a person suffer in pain and discomfort should be a wake up call. Excellent case Buckeye Surgeon.

Bobbi Gilbert said...

Hello, I came across this tonight, and today is 11/05/2014. I Lost my Dad last year on 11/21/13 because internal bleed that caused ischemic bowel. As a surgeon who did the right thing with your attempt to help even with such a small chance was the right thing to do. A chance is that simple, the possibility that they have a chance no matter how small. You did the right thing you gave the patient her right to a chance to maybe survive, and in the chance you gave the patient you also gave her family the peace that you did everything possible to help her with her small chance to survive. You more than likely are a huge successful surgeon now here in 2014 and perhaps you may never look back on this day anymore, but if you ever reflect on this post all these years later I want to thank you for giving this 87 year old the chance... you did the right thing