15 NOV 2007 Opening the road
Today I helped to admit a patient who had overdosed on antidepressant medication. We have had a number of overdose patients come to the hospital recently. Two have overdosed on Tylenol. An acetaminophen overdose is an awful way to go, both for the patient and the doctor. The medicine is such a wonderful means to treat pain, and has very few side effects. The body can remove a little bit at a time, using the cells of the liver. The liver can only work so fast; it has a limit to how quickly it can cleanse the blood. When a person takes too much acetaminophen, they get a toxic level in the bloodstream. The liver cannot speed up how fast it removes the drug. Unfortunately, a toxic level of acetaminophen begins to kill the liver cells. We have some drugs we use to defend against this damage, but we can't get it out of the body any faster. If the liver is fatally injured, it is a terrible way to die, and incredibly difficult to treat. The liver produces proteins that keep a body from bleeding, so the blood thins and a person can bleed from any hole. The liver converts many toxins in the blood to safe forms, so these toxins begin to build up and make a person disoriented and eventually comatose. This all happens slowly.
When we check if a person's brain is working, we ask questions to determine if they are oriented. If they know who they are, where they are, and what day it is, they are oriented to person, place, and time, or oriented times three. The patient who overdosed on antidepressants answered that it was Thursday. I didn't know if he was right. I know who I am and where I am, but often lose track of what day it is.
I helped Urologist S. in the operating room today. He worded on a patient we care for together, a young girl who was shot in her pelvis. The bullet injured her colon and her ureter, the tube from the kidney to the bladder. She has been home for several weeks, and we are planning for the day when we can reconnect her intestines so she doesn't have to poop in a bag. Urologist S. used fine instruments to look into her bladder and detect a narrow spot in the tube to the kidney. While he worked, he could see the scene insider her bladder on a small video monitor, and he also watched the shadow if his instruments and tubes on a video x-ray machine called a fluoroscope. I helped by moving the fluoroscope around to get the the best view. Urologist S. had to place an internal tube to hold open the blocked part of this girl's ureter.
The blockage in the ureter and the ugly swollen scar on the girl's abdomen are both signs that her belly will be full of dense and complicated internal scars called adhesions. We are looking ahead to a long operation some day in the future. The girl and her parents are impatient for her to get rid of her ostomy bag and be able to use the toilet again. We have to bide our time for the best day, and try to get it done right in one operation. We have to get both roads back open, the colon and the ureter. I'm assigned to this hospital for a while more, but I know that my time here is finite. I may be disoriented to the day, but I realize that I will not be here forever, and I have a responsibility to make sure that the work I do is going to last. Back home, I have the luxury of knowing that I will be there for a long time after surgery to take care of any problems that surface. Then again, at this moment, while I care for patients in Iraq, I am not there for my patients back home. Everything is temporary. So we count the cards, calculate our odds and make our best bet. I don't know the future, but each day I'll seek the best choice available.
"If you decide not to decide, you still have made a choice."