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.