July 5, 2009

Emergency surgery

I was delighted to hear from two people this week that I didn’t post last Sunday. Thank you for noticing.

I didn’t post because I was called out in the middle of my Sunday evening activities for an emergency – bleeding after a tonsillectomy. It is a very scary event to be sitting at home or sleeping about a week after your tonsillectomy, and then suddenly feel a warm liquid in your mouth that you either swallow or let run out, and then look in the mirror or in your hands and discover your own blood. It really gets your attention, and mine too because a ton of blood can be lost quickly. So the story, Bethany (a pseudoname) is 17 yrs old and had had multiple bouts of strep throat this past year. She would get very nasty sore throats that kept her home from school days at a time. So it was quite reasonable to see me to have her tonsils removed. No problem, operation went well, immediate post op no issues, until that 7th day post op and the blood in the mouth thing. I was home doing some computer work when the call came. Out the door two minutes later (and it’s this sudden change of plans that I will address), speeding to the ER, saw her and her panicked mother, called the OR to get ready, took her back and under anesthesia cauterized a pumping vessel. This was emergency surgery at its best, with the entire health care team of anesthesiologist, nurse anesthetist, ER and OR nurse, scrub tech, and yours truly coming to the plate with all their skills in a very hurried yet thorough manner. And Bethany did great, no worse for wear except that she could use a little extra iron in her diet over the next week or two, and certainly no need for transfusion. She went home the next morning feeling fine.

For many community surgeons, being on call for their practice brings this emergency scenario to life on a routine basis, perhaps not the immediate life threatening bleeding or airway issue, but nonetheless very urgent situations that must be dealt with quickly – appendicitis, perforated bowel, hip fractures, blocked coronary arteries that the cardiologist couldn’t stent, and all sorts of trauma. My most common ‘urgent’ problem is a peritonsillar abscess, an extention of infection from the tonsil into the space around the tonsil, creating all kind of swelling and fever and sore throat. The pus must be let out via the throat and if not, the abscess can progress and be life threatening, just ask George Washington if you see him in the afterlife, as its what caused his demise. His physicians applied the proper treatment of their day – ‘bleeding’ him. A recent urgent issue that required an operation on the 4th of July was ankyloglossia or tongue tied in a newborn. Baby Paul couldn’t breast feed because he couldn’t get his tongue around the nipple. But SITT came through by releasing his tongue in the OR early Saturday morning. In the recovery room his mom put him to the breast with immediate sucking of momma’s milk with success for Paul and no pain for mom. Ah another surgical success.

But for SITT and other surgeons, these emergencies and urgencies take their toll – being up at all hours, running out on family and social events, extending the workday hours even longer, weekend forays to the ER and or the OR. One can limit their ‘call days’ by sharing call duties with more docs, but the more docs the more patients and then on the day you are on call you can be guaranteed tons of phone calls and hospital visits. Or you can be solo like SITT and only need to deal with your own misery you helped to create (even if there was nothing to have prevented that post tonsil bleed, SITT did perform the tonsillectomy in the first place).

So, the bottom line for SITT is to cut and sew properly in the first place which avoids complications, and to educate my patients well so that they have appropriate expectations post op (it’s OK to have discharge or swelling or whatever if you know it is the normal post op course).

And when this fails, and I gotta go, well, it comes with the job.

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