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November 30, 2006

Unkindest Cut

My father asked me recently, "What's the scariest surgery you've done?" By "done" I assume he meant "assisted with" or "was in the same room with and was able to peak over someone's shoulder and see something of", because as a third-year medical student, I don't get to
"do" much of anything. A third of the way through the year, I think I've actually performed three surgeries (out of the 65 or so that I've "done"): I shaved down a kneecap, I did a laparoscopic appendectomy, and I cut out a big abscess.

As far as scary surgeries go, my options are limited by the fact that, here in Yankton, South Dakota, we don't do any heart or brain surgeries. So, the scariest stuff tends to be also the most common stuff: abdominal surgeries.

We do lots of abdominal surgeries, and they're all very scary. Aside from the routine risks associated with major surgery (bleeding, infection, poverty…), abdominal surgery, especially anything having to do with manipulation of the intestine (and even if you're not dealing
directly with the intestine, you usually have to move it out of the way), carries some fun and unique risks that always bob to the forefront of my mind during abdominal surgery: obstruction, ileus, and perforation.

By obstruction I mean any structural problem that keeps food from moving through the GI tract. The most common cause of obstruction is abdominal surgery, and usually what happens is the bowel gets irritated by being cut up, moved around, handled, or even just looked at, and gets inflamed. The inflammation activates a healing mechanism that causes the bowel to stick to whatever it's lying next to. When it gets stuck, this adhesion can keep the bowel from moving food along, the bowel gets distended, the distention cuts off the blood supply to the bowel, the bowel dies, then ruptures, and several pounds of septic material spills out into the abdominal cavity, which usually results in death.

Of course, most of the time patients go to the doctor complaining of symptoms of bowel obstruction long before things get too serious, but the wild thing about obstruction is that in order to fix it you often need to do abdominal surgery! A 1999 study in the fun-sounding journal Diseases of the Colon and Rectum found that patients undergoing abdominal surgery wind up with obstructions 15% of the time. So, 15%
of the time when you do surgery to relieve an abdominal obstruction, you're going to cause another abdominal obstruction. I think about obstruction during surgery.

Ileus is even more common than obstruction. With ileus, the bowel (or stomach) is paralyzed by being irritated (again, due to being cut, handled, or looked at incorrectly by a medical student) and, just like with obstruction, food can't pass through it. The good news is that
ileus is usually temporary, causing a few days of bloating, abdominal pain, and constipation. The bad news is that it's not always temporary, and can result in all the nasty complications of
obstruction. Also, often patients aren't allowed to leave the hospital until they've had a bowel movement, which can take a week or more.

During this time the patients are lying in bed, bloated and groaning, being bombarded by all the aggressive and antibiotic-resistant bacteria that live in hospital rooms, watching lots of TV that
features lots of commercials of personal injury lawyers. I think about ileus during surgery.

Finally, perforation occurs when some part of the GI tract gets poked, slashed, cut, or torn. This can happen during surgery. Once, when I was "doing" a laparoscopic appendectomy, the surgeon asked for graspers (kind of like blunt pliers). The room was very dark because
the camera we'd stuck in the patient's abdomen wasn't working very well, and the surgical tech handed the surgeon scissors instead of graspers. The surgeon tried to grasp the bowel with the scissors, and, for medicolegal reasons, I can't tell any more of this story, except to say that the
patient's okay. I do my best not to think about perforating a bowel during surgery.

So, a few months ago I was doing (and I actually did some cutting, poking, and sewing on this one) exploratory surgery on a patient with bowel obstruction and air in his abdomen. The air in the abdomen (or pneumoperitoneum) was a very bad thing, indicating that he probably had a perforation somewhere. He'd had previous abdominal surgery, so we were also looking for adhesions. What we did was pull the patient's small intestine out through a slit in their abdomen and piled as much of it was we could get out onto their belly. Then I carefully went hand-over-hand along the intestine (All the while thinking to myself "You're handling it! You're looking at it!") trying to find the perforation or obstruction. I couldn't find anything. The surgeon tried, he couldn't find anything. We covered the bowel with damp
cloths to keep it from drying out. We squirted some dye down the patient's esophagus to see if it would leak out of the GI tract anywhere. It didn't. An hour passed while we stared in a puzzled
fashion into the patient's abdomen. I began to feel sweaty. I had to change my mask because it kept fogging up. I would catch myself thinking about ileus, obstruction, and perforation, and my eyes would go unfocussed. I started to feel light-headed. "Great," I thought to
myself. "Let's see, the bowel is probably perforated somewhere. You've handled it, looked at it, dried it out, and now you're going to faint into the hole you've cut in the abdomen?" I flexed my legs to pump blood up into my brain. I took deep breaths. I wiggled my toes. Finally, the surgeon shrugged, and we closed up the patient. He never went home.

November 21, 2006

More Than a Slice of Pumpkin Pie

Ah! on Thanksgiving day, when from East and from West,
From North and from South, come the pilgrim and guest,
When the gray-haired New Englander sees round his board
The old broken links of affection restored,
When the care-wearied man seeks his mother once more,
And the worn matron smiles where the girl smiled before.
What moistens the lip and what brightens the eye?
What calls back the past, like the rich Pumpkin pie?

John Greenleaf Whittier, The Pumpkin.


We’ll leave most of our cares behind for few days in less than thirty-six hours … And counting.

Truly.

The past couple of weeks have been busy ones for Joel, Adelaide, and I. Besides revving up for our mid-December youth production of Much Ado About Nothing, hunting for gainful nursing employment to ring in the New Year (or sooner), Christmas shopping and parcel wrapping, surgery assisting, diagnosing, birthday celebrating, and teething, we’ve been preparing for our first road trip to Minnesota since early September. And I must admit, I’m looking forward to getting on the road.

We’re planning a brief layover in Brookings to dole out a couple of hugs here and there, and then on to the homes of Adelaide’s Grands to celebrate Thanksgiving. Although I’m anxious to see and be seen, I’m really waiting for that lovely moment when we’ll all pile snuggly into the car, pop Jonathan Strange and Mr. Norrell into the tape deck, start our engines, and find some renewal that only the open road can bring.

Happy Thanksgiving!

November 17, 2006

A Purrrrr-fect Resting Place

Sit n' Wiggle

Adelaide is on the go-go-go these days ... She's not quite mastered her crawl, but that doesn't prevent her from getting around in the blink of an eye. And just this week she decided to crawl up the side of the sofa and see what there was to see of the living room from a nearly two-foot high vantage point.

The one thing that gives Adelaide pause is a funny little birthday gift I received this week from some thoughtful friends: a foot massaging kitty slipper pillow thing. She loves to sit on the pillow and play with the kitties' heads while the massager inside the pillow makes her whole torso wriggle and shake. May I recommend it for all of the Under A Year holiday wishlists out there? It's just too much fun!

November 13, 2006

Produce

Adelaide gives a discerning glance toward the garlic.

As it happens, Adelaide's been playing around with fruits and vegetables for nearly two months now and although she's entirely ready and willing to sample new flavors, Joel and I have been running out of inspiring spoonfuls.

Early on, Joel and I decided that we would invest the time and energy required to make all of Adelaide's solid food. No small task, even when we all can eat the same thing. For example, squash is a delectable vegetable loved by everyone in our home, but everyone prefers a different style of preparation. Around four o' clock, as Adelaide plays with her Tupperware containers nearby, I'll peel and chop half a squash into small cubes and throw it into the steamer for twenty minutes, while the other intact half of the same squash will be elegantly dressed and then stuffed into a 400º oven to bake for the better part of an hour. When we all gather around the table in the evening to fill our bellies with a reviving, comforting meal, I feel a sense of pride. It feels good to home-make my family's food with produce from local farms. But it does necessitate a certain amount of creativity and effort.

An effort that all too easily floats away on a breeze of convenience and boredom.

Lately, we've had a jag of the same-old, same-old butternut squash puree, applesauce, and peas. Adelaide had been refusing her portions during the supper hour, so we decided to start something new, something store-bought. We purchased a package of organic barley teething biscuits, and two pint-sized cups of organic pureed carrots.

Adelaide devoured the carrots, and whenever she sees a biscuit she flaps her arms up and down in excited anticipation.

The homemade food rarely receives this reception.

What are we to do? I suppose a mix n' match diet is a good compromise. A Cheerio or two here, paired with a delicious puree of organically-grown parnips there. I loathe the Slippery-Slope Argument, but still, it feels like introducing a little bit of food from a package will lead Adelaide to a world of Starbucks breakfasts, McDonalds's lunches, and Applebee's suppers.

And for those of you in Toadsland who are especially astute observers, you'll note prominence of our friend, the pig, on Adelaide's outfit in the above photo. Please be assured that the applique is not a menu request for Soused Hog's Face.

November 6, 2006

A Change in Vision

I’ve worn contact lenses since I was in the 4th grade.

Yup, ever since I achieved 10 years of age, I’ve been resting tiny circlets of plastic-like material over my pupils each day to enhance my vision. But, of course, with great power (like being able see better than 20/20 with my fashionable gas permeables) comes great responsibility … A responsibility that took years to master.

I suppose I’ve lost about ten contact lenses since I began using them … Starting in Mr. Rathbun’s 4th grade, when in my polka-dot bubble sailor dress, my peers and I left our math books open on our desk and walked down the long green hall to the gym sock-smelling auditorium to have our class photo snapped. Somewhere in that hallway, between Mrs. Winkle’s 1st grade classroom and the water fountain, one of my contact lenses escaped me. Maybe I blinked too many times in a row, or perhaps I tried to look a little too far to the left at Todd What-His-Name walking behind me, but either way a little green-blue lens popped out of my eye, and landed somewhere on the linoleum … The blue-green linoleum.

Our class, including myself (sans vision in one eye), marched down the hall, lined up on some prepared bleachers and had our photo snapped. And because was wearing my polka-dot bubble sailor dress, and because it was the late 80s and I was in that gangly phase of youth, and especially because I couldn’t see very well, I didn’t take a very good picture that day.

Second Row, Second from the right.


But, never fear, this story has a happy ending … After the moment was immortalized on Kodachrome, I casually sauntered over to my teacher and mentioned that I had lost an expensive piece of equipment, and that my mom would just kill me if I came home without it; back in the day, those babies would set you back about $70 a lens. So, my entire class made its way back to the classroom at the end of the long green hall on our hands and knees, gently patting ground for any sign for my precious, concave disc.

When the search party had been boiled down to just a few stragglers hoping to avoid the coming math quiz and a handful of good friends, Mr. Rathbun called off the search. He opened his mouth and began to say, “Aimee, I think you’ll have to go to the office,” but only got as far as, “Aimee, I th …” before The Miracle happened.

Every 4th grade class has their picked-on, bullied, teased kid, and my 4th grade was no different. Who knows why one kid becomes The Class Clown and another becomes The Most Popular Kid in School and yet another becomes The Kid Everybody Makes Fun Of? Maybe it’s because they have funny hair, or maybe they ate more than the socially acceptable amount of paste in Kindergarten, or maybe it’s because they were just a little weird one day and the moniker painfully and horribly stuck.

Our Made-Fun-Of Kid was named Matt. I won’t describe him with words, but scan the faces above and you’ll find him there. You’ll find him in me, and you’ll find him in faces that remind you of yourself, because we’re all a little the Made-Fun-Of Kid in the 4th grade. It’s just harder to see it when you’re living it, isn’t it?
Back to The Miracle … Mr. Rathbun was about to send me to the office, to call my mom, and tell her the bad (and expensive) news, when Matt ran up to us and said, “Does the thing, your contact, look like a little piece of green glass?”

“Well, yeah, I guess so,” I hesitantly remember replying.

“Is this it?” And there, perched on his grubby little pointer finger, was my contact lens.

And, here’s The Miracle, for the rest of the day the Made-Fun-Of Kid was a Hero in our classroom. And for the rest of the school year, he was my own Hero, having saved my bacon from a fate worse than creamed corn (i.e., having to fess up to my mom about losing a contact). But, more importantly, that day he saved me from a dark, blurry world, literally and figuratively. For me, a twist of fate where the Dork – not the Cute Boy or not the Smart Guy – saved the day forever changed my adolescent worldview.

Who knew that a tiny little circle could have such a powerful impact?