On Call on a Saturday Night
I have been called in the middle of the night. It is fortunate that it is a Saturday night, because on Saturday nights I engage myself with some reading or studying, if I am not on-call or at work. In this particular instance, I was busy reading about Human evolution and its origins, a topic of particular interest of mine. Thankfully, aside from a passing reference, it is not going to have any further bearing on this missive. A patient had presented with a perforation and the surgical team was requested to attend, seeing that I was in the town overnight, and the term "resident surgeon", here has come to mean a surgeon permanently here. I asked for a little more context, and satisfied, I proceeded to get ready to leave. I gathered up my jacket and patrol cap, a flashlight, and put on my boots. Perforations are serious surgical emergencies, and the sight of one on an X-Ray raises every alarm bell in my mind. I was informed that a perforation was confirmed on X-ray, and in my mind's eye I could see it, the free air collecting under the diaphragm on both sides of the chest, pushing it upwards in a curve that looked almost obscene. In some ways, the aberrant anatomy of the body in sickness is obscene and likely so, because it violates the understanding of the unified nature of the anatomy and physiology of the body.
I do hesitate to use these emotionally charged words considering for a minute the rest of the patient, a 90 year old woman with colorectal cancer with metastases. The medical history was a series of unfortunate conditions, heart failure, Chronic Obstructive Pulmonary disease, liver metastases, and of course some enlarged lymph nodes along the arteries of the colon. Considering the whole of the patient, I had little reason to be hopeful. Seriously comorbid patients, especially the elderly and frail make up the bulk of the acute surgical care patient population here, and this patient's particular perforation didn't surprise me in any way either. What surprised me was the almost mechanical resignation not to the act itself, but to the likely outcome, that I would operate and do the best I could.
I cannot claim that this sudden revelation is either new or entirely original. There are guidelines, other surgeons' experiences, and of course academic material that tell us what to expect. The underlying theme is always to attempt rescue first. I recalled other patients with similar perforations and comorbidities, but this patient was the most serious so far. I reasoned that the patient might be more serious than my previous patients, but the work of surgery itself was just this, the building upon foundation and experience. Further, I argued against caution that emergencies do not allow much leeway in terms of options. We must operate on perforations; there is no other way.
An hour or so later, I am in the OR. It is one o'clock in the morning. The incision opens up an abdomen that inspires no confidence. There is fecopurulent fluid everywhere in the abdomen, the intestines look as if they have burned with acid. Upon closer inspection, we find the site of the perforation, just above the colo-sigmoid junction, below which is a large tumour formation. Large black lines snake across the surface of the intestine. It is clear that the tumour has eaten through the outer wall of the intestine, and the surrounding lymph nodes themselves are hardened. We lavage the abdomen multiple times, identifying more metastases, in the liver, in the mesentery, in the sigmoid itself, and I am quite sure that there are metastases to the lungs too. I look at the tumour, coiled in the pelvis and it stirs within me a sense of visceral horror. The last CT imaging we had access to was almost five months old, and its description amounted to little more than “advanced adenocarcinoma, with metastases,” without further anatomical or staging detail. It described an aggressive stage 3 tumour with local metastases, but this was a tumour in its end stages, when it has grown and consumed everything in its path. The collective decision by the senior surgeons was to attempt source control first, and then perform a segmental colectomy and a diversion. A colostomy was created and the rest of it was left to the enormously complex work of the body's own microcosm and critical care. We had done our part.
By the time I returned home, I realized that I had time for 2 hours of sleep, which passed fitfully. When I woke, I searched through the existing guidelines for critical care in surgical patients and read as much as I could while racing through my morning routine. I did not dwell on fatigue; there is very little choice in emergencies, and this was the work before me. I had read enough of Stoicism to know that now was not the time to repeat dictums from antiquity, but to throw myself into my work with clarity and attention. There is no need for heroism here, I thought to myself as I reached the hospital for the morning rounds, and even if there was a need for some form of heroism, I doubted that it would serve any purpose.