In medical school, I attended a lecture on acute appendicitis. The appendix, as we commonly call it in today's culture, true name is the Vermiform appendixis, meaning the worm. The ancients felt that this fine earth dwelling creature most resembled this unusual organ. In said lecture, it was mentioned that about half of people who presented with acute appendicitis would die from the disease in the times before antimicrobial treatment. Among the surviving half, a large portion would depervess, and some would form chronic/contained abscesses, which would resolve over time or break open and kill the poor unfortunate soul. Before the time of antibiotics, surgery didn't provide a benefit, as the wound was "dirty" (a dirty wound is one considered to be contaminated with bacteria, in this case stool being an excellent source for bacteria), and the complications of wound infections would kill those who survived the surgery. Now, with our modern medicine, the death rate in the US is less than 0.1%.
Several years have now passed since that lecture, which brings us to the morning of June the first. I had just completed a very nice two week vacation. I spent a large amount of my time studying for the
USMLE step 3, which I had planned to take at the end of this month so I could apply for my unlimited license - yep in the next six months I will have my
DEA number, and the ability to practice medicine unsupervised. It was intended that I would begin my ED, or as others would say ER rotation on Monday. However, at two o'clock in the morning, I awoke with bit of a cramp.
Now the readers must forgive me for my precise account of details of the following days. During this time I was in a delirious state of mind resulting from infection and medications. This being said, I remember that the pain (my only discomfort at this time) which awoke me was thought to be a gas pain. The night before I was hungry (the last time that I would have that sensation, and I'm still waiting for its return) and I found some cottage cheese. It smelled and looked right and I ate it with great satisfaction. Unbeknownst to me, well at least until after I had finished my snack, Bryn-Erinn informed me that it was over two months old and that she didn't realize it was still lurking in the refrigerator. A point that I neglected, as I didn't look at the expiration date before consumption.
Now, this being known, it does not surprise the reader, nor myself at the time, that I might have a bit of a bellyache the morning after devouring said cottage cheese. I walked and stretched trying to move what I thought was a foul ingestion through the gut. However this was not to my advantage, and the pain grew in severity. I did however empty the contents of my stomach, but it oddly did not make me feel better. In spite of this, it was slightly reminiscent of another post which one may find on the 13th of January of this same year.
By five that morning the pain was so bad that I had emailed the rotation director of the ED and told him that I would not be able to come in on my first day, but that I would try to be ready to join his ranks the next day. I later discovered that in this hope I was over zealous and nature had a different course for me. To my surprise my belly became stiff as a board, or as we say in medical circles, "rigid". By nine o'clock that morning, I asked Bryn-Erinn to drive me to the Southdale ED to be evaluated. At check-in I was relieved to see that my "vitals" (heart rate, temperature, blood pressure) were all in the normal limits, and thus my concern was not increased. The staff doctor was delayed due to a heart attack patient, and I lay on the gurney in room six for 90 minutes before being seen.
The doctor's exam confirmed my own self-exam, and I was guarding, another way to say that I was holding my belly rigid to prevent any movement of the tender insides. This most often suggests paraneal inflammation, which is rarely a good sign. I was sent to the CT scanner to have my insides investigated, but the findings were not impressive. On the report it stated that there was some pelvic fluid, but otherwise nothing of note. Similarly an ultrasound was preformed, which did not show any stones in places they aught not to be. My blood work also returned without a clear source of the pain, showing that I had an inflammatory process as indicated by my increased WBC (white blood count). However the good doctor overlooked the elevated bilirubin, which to the more astute practitioner, would have suggested that I was sicker than what her studies were finding.
After a very long day, I was sent home without a diagnosis. I begged for some narcotic pain medicine, as at that point it was only the large doses of morphine that were keeping me sane. She gave me a modest supply and I returned home to face the shards of glass imagined within my belly. I do not remember the next 16 hours. I know that I took the pills to keep the pain under control, but each pill would cast me into a most unrestful sleep. The hours passed quickly, and the next day arrived. When I awoke, Bryn-Erinn had left for work. I'm sure that she gave me commands to call her for anything, and she would rush back.
When I did finally arise from my bed, the pain was somehow worse than the day before, as if this was some sinister plot derived for me from a person without a heart or soul. I took my temperature, which showed that I had a temperature greater than 102. And although not observed by me, Bryn-Erinn later commented that when she found me, upon her return, my heart was beating so fast that it looked as if it was in my neck. I again emailed my rotation director and conveyed the details of the day before, and I again told him that I would not be present to his instruction.
Not wanting to disturb Bryn-Erinn, as this is how logic occurs in the delirious male mind, I patiently waited at home, not moving, waiting for her return. I also called my clinic mentor, Dr. Sick, to confirm that I should go to the ED again, as the ED stated clearly on their paper work that I should not return within the next 48 hours. If this would seem odd to the reader that I would have such doubts about returning to the ED in such a state, again, I emplore you to understand that I was, at this time, in a delirious state of mind and normal human logic did not apply.
At the triumphant return to the Southdale ED they greeted me with open arms and a wheelchair. They confirmed that my temperature was elevated, and my afore-mentioned heart rate was 140. To my benefit, my blood pressure was still in a good range, although this is always the last to fall. My pain had migrated to the right side of my lower belly, except for the times it would lash out in anger and involve the whole of my lower belly. The obvious displeasure of my insides had become quite an agitation to my diaphragm, and I had intermittent hiccups which would only add fuel to the raging fire I had once called my gut.
The physician on this day was quite involved with the very matters that were never explained to us previously. In the interim the nurse had me drink oral contrast for the second day in a row in preparation of a possible CT scan. Not common knowledge, but known to the nursing staff and clever house staff in various hospitals, oral contrast has a way of slicking the gut that few other compounds are known to do in this world. It was once said that only manual disimpaction is superior to the action of this powdery liquid.
After three hours of waiting, watching my heart rate never dip below 120, the physician came and examined me. He damned the nurse for giving me the contrast, and with only the briefest of interview and the quickest of exam stated that I need surgery of that very day. He ordered ertapenum, but he called it by the name of Invanz.
I would wait another two or three hours on that gurney in a room that I don't remember before the surgeon appeared. He stated that we were in the line up for the operating room, but that the line was long. He hoped before seven o'clock that evening, but it could be longer. He checked on me from time to time, almost to rival the nurse staff, with the exception of checking on my blood pressure hoping that I would not drop it before they could save me.
Finally it was time for the operation. I was in the waiting room to the OR, writhing in discomfort, trying to find a position to relieve the misery in my abdomen. However from that time forward is a blank in my memory. It is for sure that I met the anesthesiologist who gave me a cocktail of drugs to wipe that time from my memory. In due order, from my experience: I received a gentle kiss by the lovely Bryn-Erinn; moved into the operating room; put to sleep; had a breathing tube placed; my belly cut open and placed on display; and the offending appendix removed. Bryn-Erinn tells me that I was still in distant travels in my mind when she last saw me exit the operating room that evening, but everything had gone in my favor. The surgeon later confided in me that my belly was full of pus, and a small sample was obtained for laboratory examination, not that it was likely to reveal anything more than what would be cultured from a common stool. Had I not received that life saving procedure, I would have ended my existence in this realm in no more than two sun rises, and undoubtedly been overcome by septic shock.
As for the remainder of this tale you will need to continue on to part two.
The fearless guide.
Views of the St. Croix
