#175 Shanksteps
I first saw her in clinic. Her nomadic, bright colored attire, hid her frame. She said her stomach had been growing. I asked how long, and the response was 10 years. Hernia? Cancer? Baby? (the time frames I am given often do not apply to the current episode of things happening, but may be an accumulation of events that the patient relates together). I examine her and fine a huge abdominal mass that seems to be little mobile, maybe 10X10X13 inches. I did an ultrasound. It appeared solid and cystic (little fluid pockets). Likely a cancer.
She took the “standard” bowel preparation the day before yesterday. She took it all and had NO stool. So she did it again yesterday with even more bisocodyl. Finally she had a lot of diarrhea and cleaned out.
She lies there with cachectic arms and legs, with a VERY protuberant abdomen. Lying on the operating room table, she takes up a small portion of its 1.5 feet width. She looks embarrassed as we uncover her to start the preparations for surgery. We administer Valium, atropine and Ketamine; prepare her abdomen with betadine, and lay on all the cloth drapes. She has NO fat on her body. So once I’ve cut through the skin I’m nearly inside. Usually when I’m working on a belly this protuberant I’m apprehensive because I’m wondering if the baby is going to be OK. Now I’m apprehensive because I don’t know exactly what I will find. Where it will be coming from and if I’ll be able to take it out. I see intestine stuck to the surface. Huge vessels feed the mess. I feel below it and don’t feel a free spot, neither on the sides and top. So I slowly start freeing the intestines from its surface. There is oozing everywhere. We give her Vitamin K in hopes that she might be low in Vit K and that this would then help. It doesn’t seem to. I control the bleeding with some sutures. We continue the slow work. Freeing up here and there around the sides of it. Now I’m behind the large intestine and behind the stomach. The pancreas is in view, it’s rather stuck to the cancer. I realize that all the large vessels that feed the intestines are within this cancer. It is impossible to remove. So we decide to close. The nurse giving the anesthesia recommends that I call a family member into the operating room to see what we have found and to explain why we cant take it out. I call in an uncle that is a person I recognize as having seen before. The nurse puts a mask on him and a cap and he comes in the door. The nurse stands behind him to assure that if he passes out he doesn’t hit the floor. He takes it all in without emotion. Thanks us for trying, and states it is God’s will. Though I desperately disagree with the last statement, I say thank you and he leaves. We close up the abdomen and take her back to her room to wake up. I instruct the nurse to get vital signs on her every hour for four hours, knowing it will only happen if he has nothing else to do. G