Tuesday, January 30, 2007

Droppings of the Stoma Bird

It's been a busy time around chez DocSurg after our recent move --- and, no, the snow still hasn't melted enough for me to catch sight of my sidewalk yet. Just to keep things interesting, I have been overwhelmed at work as well --- big cases, small cases, full offices, driving between hospitals and surgery centers --- and, of course, loads of call to keep me occupied.

Ah, well, it could be worse. I mean, patients still show up at my door and let me open them up to poke around inside them! That's a pretty cool trick -- "Hi, I'm Aggravated DocSurg. You need surgery. Trust me, it will be painful. There are risks. It's not often very pleasant. But in the long run, the goal is to make you healthier. And did I mention that it will hurt?"

Sometimes there is an additional issue. Pain, inconvenience, fear, worry, and all the other difficulties of surgery aside, there is one thing that always causes more consternation among surgical patients than any other: a colostomy. Colostomies happen to be weighing on my mind lately because I have been acting as the "Stoma Bird," dropping 4 newly created colostomies in 5 days --- only one of which was a scheduled and planned procedure --- one abdominoperineal resection for rectal cancer, one Hartmann's procedure for sigmoid volvulus with resultant bowel infarction, and two additional Hartmann's procedures for severe diverticulitis with percutaneously inaccessible pelvic abscesses.

Of course, none of these patients were taken to the OR without being fully informed that a colostomy was a (near) certainty. Even so, particularly for the emergency patient, the preop discussion of ostomies and their function is quite a far cry from actually waking up with one. Most patients have essentially zero experience with or information about ostomies, but one thing is nearly universal --- they really, really don't want one. I would say that this feeling, while normal and understandable, can be handled with better education.

Please don't get me wrong. I would not volunteer to have a colostomy, but it is sometimes our only option in the OR. When discussing them with patients, I try to put them in the broad context of everything else we do to try to make people better. With that perspective, the creation of an ostomy, whether permanent or temporary, is not so much different than giving antibiotics, respiratory therapy, cardiac meds, etc.

A properly created ostomy, made under optimal conditions in the ideal patient, can be viewed as a success --- perhaps by the surgeon alone, but a treatment success nonetheless. The ideal patient is rarely found, and optimal conditions are surely never present in the urgent setting, and so general surgeons are frequently put in the position of playing the cards we are dealt. The obese, septic, hypotensive patient with peritonitis from perforated diverticulitis can present an enormous challenge to what would to the non-surgeon seem to be a straightforward procedure. Consequently, stoma problems are occassionally seen -- retraction, ischemic necrosis, prolapse, parastomal hernia --- most of which will require additional surgery.

Fortunately, three of my recent "Stoma Bird droppings" will be able to be reversed in the next few months --- certainly helpful, as their stomas were created "on the fly" in the OR without the benefit of preoperative teaching and site marking. The techniques for proper stoma creation, whether planned or emergent, are certainly fodder for another, considerably longer, post. But in short, regardless of the situation, we aim to fashion a functional, pouchable, and usable stoma --- and if you hear a general surgeon state that he is proud of creating a "good stoma" that "looks like a rosebud," he means it with the same pride a carpenter has when he's finished with a piece of fine woodworking.

Tuesday, January 02, 2007

Just a little friendly advice

FYI, for anybody who may be so obtuse as to try --- let me give you a bit of advice. The kind of advice that comes from actually doing something so obtuse:

Don't. Move. During. The worst pre-New Year's blizzard since 1913.

For the reading-impaired:

I know this may come as a complete shock to you, but trying to move every single thing SWIMBO, the Surglings, and I had accumulated in a dozen years in our old house was a bit taxing -- especially in a blinding snowstorm! It's no wonder that my permanent expression has changed just a wee bit:


and after