6 NOV 2007

Hi Friends,

I'm sorry I haven't written in a bit, but I've been running on little sleep and less free time. We haven't had a large number of patients, but the ones we have kept us busy. Last night I returned from dinner and Thoracic surgeon J. called us over to see a new patient's CT scan. He was an eight year old boy, who like many of the Iraqi children was thin and appeared much younger than he was. Earlier that day, he had been playing on a stairwell with his brother, when his brother pushed him over the railing. He fell nearly one story, breaking his fall over a short retaining wall. He cried a bit, but got up and was able to walk to his home.

Throughout the afternoon, he felt well and seemed to be acting himself. When his family gathered for dinner, he tried to eat some bread but started having belly pain and vomited. His father took him to a doctor in the neighborhood who advised getting him to the US base as quickly as possible.

In our emergency room, he lay on a stretcher and was in obvious discomfort. His belly was bloated and painful. Whenever anyone examined him, he would cringe as they touched his belly and tried to push their hands away. His pulse was strong but rapid. He went through the tube of the CT scanner, which gave us images of the inside of his belly that look much like slices of a bread loaf. On these images, we could see bubbles of air that had leaked out of his intestine along his spine and a lot of liquid sloshing around in his belly.

We brought him to the operating room just after getting intravenous catheters in his arms. He was quickly asleep and the nurses prepared his belly for surgery with a brown iodine solution. As soon as Laparoscopic surgeon S. and I opened his belly, liters of a brown liquid poured out. Fortunately there was no bleeding, but his intestines and fat were irritated because they had been soaking in the fluid for hours. The fluid was comprised of his digestive juices, saliva, stomach acid, and a solution like lye from his pancreas. There is a short tube that connects the stomach and the long loops of intestine called the duodenum, and it had burst open like a Christmas popper. The fluid from the pancreas had started to eat away at his insides, turning some of the fat in his belly into a pasty white solution like soap. The surface of his intestines was red with broken blood vessels. This type of injury is a challenge to treat, because the duodenum doesn't heal well. The digestive juices are so strong at this location that they will often eat through any repair that a surgeon makes. We were forced to close off the exit of his stomach with stitches and create a detour from his stomach to a location  downstream in his intestine. This simple blowout of his intestine required nearly three hours of surgery.

After the operation, the boy lay in his bed with tubes sticking out of holes in his belly. I explained to his father this red tube is to feed him, this yellow one is to drain the stomach acid from the duodenum, and this clear one is to catch any contaminated fluid that might leak out. He stoically watched his son and listened to me, but I could see the worry in his furrowed brow. "How long before he can eat with his mouth?", he asked; "When can he go home?" I've been taught by professors wiser than me not to promise a result in the face of an uncertain future. Don’t give the parents an artificial deadline upon which they will set their hopes. Another attending described it as leaving yourself a big back door. So I told him that his boy's life was in danger, but he should be hopeful, as I was. I said that I knew if he survived, which I expected him to, he would be in the hospital for weeks and possibly months, maybe even needing more surgery. I told him I did not know when his boy would eat, but that we would be monitoring his body very closely, watching for the signs he would give us when he was ready for food.

There are no accidents. It takes only a moment's distraction or foolishness to result in an injury that could require weeks to heal, or an even worse outcome. Staff at the base asked to interview us about some of the children who had been treated at our hospital to communicate to the local population how we had contributed. I told them that the best message they could strive to deliver was for public safety and prevention. The people who build better airbags, pass gun safety laws, and lower a building's maximum water temperature will save far more lives than surgeons ever could. Prevention is where we have power to make lives better. Surgery is just mopping up those who slip through the cracks.

We had a happy visit yesterday. The boy who was burned from his chest down to his toes came back for a clinic visit. His father told us how he was walking at home and eating well. As soon as the boy saw me come around the corner he started crying and tried to hide behind his father. Yes, we surgeons are the big meanies. He was so relieved to be back home with his family. I removed his dressings to find that all of his skin grafts and burns had sealed over, but for a few spots of scabs and skin cracks that bled a bit. He still walked crouched like an old man, but after a few passes across the physical therapy room, I had him standing upright. I took away his leg splints and his wheelchair and told him he was no longer sick. I told him that he had to go outside and play to get strong again. After the office visit, he was running late for his ambulance ride to the base security check point, but the ambulance driver permitted me a few minutes more to bring him to see the ward nurses.

All the nurses and technicians cheered him and came over for a hug. So many people had helped nurture him through his injury. They made him walk around to show them how far he had come. He was much happier to see the nurses than he had been to see me! I could see in the faces of the hospital staff such joy and satisfaction in the success of someone for whom they had come to genuinely care. I know how happy it had made me to see him and I didn't want to deprive them of the same boost. On the ward they put in such long hours treating seriously ill patients, some who won't make it. It is important for all of us to celebrate a victory.

Today is my Grandma's wake. I may not be there in person, but my thoughts are with my family. My friends at the hospital surprised me with a kind sympathy card. It meant so much to have their good wishes and support. I have been doing my best to occupy my mind and hands to get through the sadness I feel. Much of what I have been doing has been an effort to distract myself from how I feel, but today I'll be thinking of Grandma.

Be careful out there,

Chris