Saturday, December 08, 2007
He flipped the thick slab over on the white cutting board. In a different place, at a different time, you might think that we were in the kitchen, not in the sub-basement of a hospital. As he maneuvered the slice of liver, it kind of jiggled-- purple and shiny. With a probe, he poked at one of the bile ducts, digging around until he felt the scrape of the metal against something solid. With a quick twist of his wrist he dragged out the stone, black and yellow-speckled. Behind that stone, several more pebbles were lodged.
It seemed so small, but there it was, cause of death: biliary sepsis, secondary to obstruction.
This is what I was dreading in my last post. The other day, we went to the autopsy of one of my patients, the one that suddenly crashed overnight. Despite having spent hundreds of hours in cadaver lab, I dreaded this. I didn't want to be there when they opened the chest of a patient that I had talked to and examined, a patient whose family I had several conversations with. Luckily, we weren't there for the whole thing, just for the gross inspection after they had already removed the organs.
Maybe I was being over-dramatic, and when I talked to a friend, he didn't really think this was any more gory than the things I witness in the trauma bay. I suppose that from that aspect he is right. Technically this isn't any worse, but it was something that bothered me emotionally. I can deal with blood and guts. I still remember the rush during the first month of med school of reaching into an abdominal cavity, sliding my hand down the posterior ribs, and blindly finding the spleen when everyone else at the table was still too squeamish to really look for it. However, mentally I have difficulty seeing someone opened up and explored, someone that I had planned on being able to fix.
The autopsy itself was performed to find an answer. We had suspected biliary sepsis all along, but couldn't find an obstruction. The patient had a cholecystectomy several years ago that was complicated by a biliary leak. We were suspicious of there being a stone stuck somewhere in the remaining bile ducts, despite not being able to see anything on ultrasound. The patient was septic, and we couldn't find the source of his infection. His hepatic panel was elevated, like there was something stuck somewhere. When a more invasive study (ERCP) was performed to look again for the stones, the patient expired on the table.
Technically, we did everything right for this guy. He was placed on an appropriate antibiotic in the ED, confirmed later by sensitivities on his blood cultures that came back after he had died. He was fluid resuscitated, intubated, and ventilated aggressively. It was simply a case of not being able to catch up with a late presentation. The stones sat there hidden, slowly leaking bugs into his bloodstream, while the symptoms of his illness were masked from his wife by his dementia. By the time anyone realized he was sick and he came to the hospital, it was too late.
It is what can be so frustrating about medicine: when everyone works so hard to fix someone, and in the end, it's the battle of pulling a brake on speeding train already mid-air, going over a cliff.