Saturday, October 27, 2007
Doc Schwab had a post recently about whether to get your surgery at the community hospital or to go downtown to the "big freaking hospital". I posted a comment describing certain scenarios where I would recommend that the patient go to the tertiary referral center. Examples included major liver resections, cholangiocarcinomas, complicated entercutaneous fistulas, severe necrotizing pancreatitis, and liver transplant patients with any of their attendant complications. If I had to pick one case most appropriate for transfer, however, it would be the liver transplant patients. You just don't want to deal with the immunosuppression dosing, the complicated anatomy, and all the infectious issues that inevitably arise. I would assert that you ought to refer even something as seemingly benign as an inguinal hernia repair to the transplant surgeon. So what happens this week? My partner gets called at 3am one night on a patient with a bowel obstruction. He drowsily agrees to admit. The next day we find out the patient had a liver transplant in 2003. His films look terrible and he has some tenderness in the epigastrium. I called the Clinic downtown and they agree to have him transferred. A couple of hours later I get called by the floor because there's a bed shortage at the Clinic. Transfer delayed until the next day. So I have them get a CT scan, to be better delineate the obstruction, since it seems we're stuck with him at least over night. I'm raking my leaves at home and the radiologist calls. "I see a high grade SBO and, more ominously, a suggestion of portal venous gas", he says. There's also a couple of air bubbles that may or may not be outside the bowel lumen. Fantastic. I call the floor. The nurses say he's been asking for morphine every hour. I rush in to see him and he's stable, but certainly more tender. You can't mess around with a patient who's on cellcept and cyclosporine. The natural inflammatory response to stress is altered. You can't trust vitals, white count, xrays. It's all unreliable. He could be sitting there with dead bowel and you wouldn't know. You have to be aggressive. I explored him that evening. Luckily, no ischemic bowel. The "portal venous gas" was actually just pneumobilia from a choledochojejunostomy. His midjejunum was the size of a South American Anaconda, status post ingestion of a wild boar. The scrub nurse kept asking me why his "colon" was so big. She wouldn't believe me it was small bowel. I lysed everything (easily because the adhesions were flimsy and soft secondary to the chronic immunosuppression) and decompressed his bowel. He's actually extubated and progressing fairly well. We're not out of the woods yet, but so far so good. Hopefully that bed at the Clinic becomes available again on Monday.