16 NOV 2007 Stuck on you
I awoke from a dream in which I was cutting adhesions. Have you played the game Tetris? Simple structures formed from squares fall from the top of the screen, and the player has to rotate and shift them so they interlock into the existing landscape at the bottom of the screen. When it came out, people would play for hours, stacking blocks and clearing levels. After they finished playing, they would see those falling shapes in the air in front of them wherever they turned. It was called Tetris fever. The brain likes routine. It wants to keep doing whatever it is doing. All in life is habit. Work out for a week, it feels bad to stop. Don’t work out for a week. It feels bad to start. Really bad! Repetition is our comfort. Change causes fear and protest.
Working on adhesions is the same way. Adhesions are the body’s expression of excessive healing. After a surgery in the belly, or practically anywhere else, such as the chest or a joint, the body heals the damage from the disease and the surgeon. In addition to closing holes from needles and incisions from scalpels, the body starts to form bridges between tissues that are not normally connected. The body just gets into the habit of healing, and cannot stop when the job is done. Filmy sheets like cellophane join adjacent loops of intestine. Tense cords of scar link the colon to the vagina and bladder. Bridges of fat and arteries form between the colon and the inside of the abdominal muscles. The stomach and liver bond together in broad dense patches as if Super Glue had been applied to them. When a surgeon has to reenter a belly after those adhesions have formed, it is a delicate, time-consuming grind to separate all of the different organs. It can take hours just to get an open window below the layer of the muscles of the abdominal wall. Move too fast and you end up cutting a hole in the colon and leaking fecal material everywhere.
When we begin an operation knowing that someone has been in there before, we always allot ourselves extra time for the dissection of these adhesions. It is always a comfort to have another experienced set of hands across the table from us for these challenging cases. We tell the chief resident “Don’t send me the intern for this one. From the first cut through the skin and fat, we are anticipating how dense the previous internal scars will be. Sometimes we make two parallel cuts around the old scar on the skin, if it had grown wide and shiny, to excise it and hope for a better course of healing this time around. As we deepen the cut, approaching the vulnerable intestines, we slow down, separating microns of tissue, looking for a safe path into the belly. Two experienced surgeons working together can execute synchronized acrobatics of complementary motions, pulling a little here, adjusting the tension there. We breathe a sigh of relieve when we see the fluid that lubricates the intestines welling up in an open cavity between unscarred organs. Slowly working through adhesions is an exercise in seeing and feeling the border where one organ meets another then using scissors, scalpel, or the electronic arc of a cauterizing device to separate them while injuring neither.
When I drive home from the hospital after dark has fallen and the cones of light from the arc-lamps of the highway slip over my Jeep, I see adhesion after adhesion parting in front of me at the shadowy frontiers of my vision. Often I dream of them.
Tonight I removed an infected appendix from a troop stationed here on base. He is responsible for many men and women, and had a small coterie of his staff gathered around him in the ER as we prepared him for surgery. I waited to describe the operation to him and watched as he assigned them duties to perform while he was undergoing surgery. He informed them where necessary documents were located. He made it clear to us that he wished to recuperate at our hospital and later on the grounds of our base so that he would not be far from his unit. The narcotic medicine we had given took the edge off the pain but had not completely eliminated it, as was visible in the way he slowly took to his feet to use the restroom.
After surgery, he was eager to test his legs out. He calmly explained that he was feeling pain at the site of the operation, but his face didn’t betray any worry or distress. With the help of a nurse, I got him to his feet. He rose quickly, pausing only briefly in a sitting position. The color rapidly drained from his face, his eyes rolled skyward and his breathing deepened as his knees buckled. We moved quickly to support his solid frame and lift him back into the hospital bed. Less than a minute passed and he told us he was ready to try again. I work with some hard-charging roughnecks.
It is hard for some people to let go of the minutia and responsibility of their daily lives when they take ill. Perhaps it is a means of denial of the more nebulous questions posed by an illness. It is more comforting to face the concrete and surmountable problems of work that they master every day. No one ever has time for illness. We never know when or why it will come to us, but it is nearly guaranteed to come at the most inconvenient time possible. I have seen this denial of the necessity to slow down and heal get in the way of a person’s recovery. For parents of the children I treat, it takes the form of worry for final exams, football tryouts, and family vacations. I gently try to coax people into letting go of the non-physical demands of schedule and release themselves to put all of their faculties into a restful and complete recovery. It is a particular weakness of us Americans. Perhaps we just can’t get into the habit of giving ourselves time. We are too stuck in the frenetic pace of 24-hour-a-day business and connectivity. I’m one to talk; here I am at 0330 again, staring at a screen instead of the insides of my eyelids.