Saturday, December 10, 2016

My big fat botched gall bladder surgery

The three times that I could have died

If you've read my previous posts to this blog, especially Remembering Simcha and Tzvi and Yaakov's Journey, you may be thinking, "C'mon, another medical debacle? How many things like this can happen to the same family?" Well, I assure you that they did and I have the scars to prove it. It's one of those examples of truth being stranger than fiction.

And I think that with this post, barring unforeseen circumstances, I'll have covered the subject of family medical dramas.

The first time that I could have died (1976) occurred about a year after my preemie twins were born and died (see post Remembering Simcha and Tzvi).

I went to the emergency room on Shabbat Shuva with severe abdominal pain, and was diagnosed with a urinary tract infecion and sent home with antibiotics.

Then, on Erev Sukkot, while at work, I again experienced severe pain and an ambulance was called to take me to the emergency room. By the time the ambulance arrived, I experienced temporary blindness - I could hear what was going on around me, but my visual field was completely black. It lasted at least a couple of hours, or until I was under general anaesthesia, and was extremely frightening.

I have never been given a satisfactory explanation for the loss of vision by a medical professional, but this is my lay self-diagnosis:

Conversion Disorder
Conversion disorder begins with some stressor, trauma, or psychological distress. Usually the physical symptoms of the syndrome affect the senses or movement. Common symptoms include blindness, partial or total paralysis, inability to speak, deafness, numbness, difficulty swallowing, incontinence, balance problems, seizures, tremors, and difficulty walking.

The surgeons opened me up not knowing what they were going to find, but it turned out that I had an ectopic prenancy, with the fetus growing in a fallopian tube, which had to be excised, as continuing growth of a fetus outside of the uterus can kill the mother.

Thankfully, when I awakened from the surgery, my vision was totally restored.

A short while later, a friend told me that his sister-in-law had experienced the same symptoms on Erev Pesach. Not wanting to worry anyone, and intent on finishing her Pesach cleaning, she told no one of her pain and was found dead on the floor.

The second time that I could have died is described below.

The third time occurred about 3 years ago (2013), when my blood glucose level climbed to 565.

The doctor at the emergency care center told me that most patients with such a high glucose level come in to them in a coma. If I had fallen into a coma, it might not have been discovered for quite a while, as I was alone at the time.

The second time I could have died (1996)

After weeks of intense pain, I was diagnosed with an inflamed gall bladder and gall stones.

I was the stereotypical gall bladder patient: female, forty, fat, and fecund.

I underwent laparoscopic gall bladder surgery at Shaarei Zedek Medical Center, and when I woke up from the surgery, everything seemed fine at first. I felt as good as I expected to a few hours postsurgery. However, when the nurses checked the drainage tubes in my abdomen, they became concerned. Apparently, bile was filling one of the tubes, and it wasn't supposed to.

The surgery had taken place in the morning, and mid-afternoon, the surgeons breezed into the room and asked the half-dozen or so visitors in the room, who were there for the patient in the bed next to me, to please leave, because they had something important to talk about to the Walks. They then proceeded to tell us that there had been a complication in the surgery and that I would have to have an additional surgery done, this time conventional (roux en y hepatic jejunostomy). An expert on the procedure that was to be done was being flown in and the surgery would take place at midnight. It was rather dramatic...

What they didn't tell me was that what they referred to as a complication was actually a surgical error. They had mistakenly cut the wrong duct.

While laparoscopic surgery has a fairly short recovery time, usually about a week, this surgery took me about a year to recover from, and I'm not sure I ever got back to the energy level I had had before the surgery. I was left with a Y-shaped scar impressive enough that if I ever have imaging done of my abdomen, it elicits quite a reaction in the imaging technician.

I've been asked if I considered suing the surgeons. I did, briefly, but eventually decided not to take any action in that direction.

Let me explain why with the help of an excerpt from the book, "Complications: A Surgeon's Notes on an Imperfect Science," by surgeon and author Atul Gawande.

"Today we've learned to take out gallbladders with a miniature camera and instruments that we manipulate through tiny incisions. The operation, often done as day surgery, is known as laparoscopic cholecystectomy, or "lap chole." Half a million Americans a year now have their gallbladders removed this way...

Removing the gallbladder is fairly straightforward. You sever it from its stalk and from its blood supply, and pull the rubbery sac out of the abdomen through the incision near the belly button...There's one looming danger, though: the stalk of the gallbladder is a branch off the liver's only conduit for sending bile to the intestines for the digestion of fats. And if you accidentaly injure this main bile duct, the bile backs up and starts to destroy the liver. Between 10 to 20 percent of the paients to whom this happens will die. And the survivors often have permanent liver damage and can go on to require liver transplantation. According to a textbook, "Injuries to the main bile duct are nearly always the result of misadventure during operation and are therefore a serious reproach to the surgical profession." It is a true surgical error, and, like any surgical team doing a lap chole, we were intent on avoiding this mistake...

Using a dissecting instrument, I carefully stripped off the fibrous white tissue and yellow fat overlying and concealing the gallbladder. Now we could see its broad neck and the short stretch where it narrowed down to a duct, a tube no thicker than a daisy stem peeking out from the surrounding tissue, but magnified on the screen to the size of major plumbing. Then, just to be absolutely sure that we were looking at the gallbladder duct and not the main bile duct, I stripped away some more of the surrounding tissue. The attending and I stopped at this point, as we always do, and discussed the anatomy. The neck of the gall bladder led straight into the tube we were eyeing. So it had to be the right duct. We had exposed a good length of it without a sign of the main bile duct. Everything looked perfect, we agreed. "Go for it," the attending said...

I got the jaws around the duct and was about to fire when my eye caught, on the screen, a little globule of fat lying on top of the duct. That wasn't necessarily unusual, but somehow it didn't look right. With the tip of a clip applier, I tried to flick it aside, but instead of a little globule, a whole layer of thin unseen tissue came up, and underneath, we saw that the duct had a fork in it. My heart dropped. If not for that little extra fastidiousness, I would have clipped off the main bile duct.

Here was the paradox of error in medicine. With meticulous and assiduous efforts to ensure that they have correctly identified the anatomy, surgeons need never cut the main bile duct. It is the paradigm of an avoidable error. At the same time, studies show that even highly experienced surgeons inflict this terrible injury about once in every two humdred lap choles. To put it another way, I may have averted disaster this time, but a statistician would say that, no matter how hard I tried, I was almost certain to make this error at least once in the course of my career..."

Human beings make mistakes. I don't believe that surgeons should be punished for being human. Perhaps if I had suffered serious injuries, I would feel differently.

Interesting side note:
This was one of two instances in our family in which family members experienced medical issues that seem related to the person after whom they were named.

My paternal grandmother, after whom I am named, died from complications of gall bladder surgery.

My father-in-law, after whom Yaakov is named, died from a complication of diabetes, namely an abscess that was located next to the same cranial nerve that housed my son Yaakov's tumor, and he had some similar symptoms: hoarse voice and a partially closed eyelid.

I have no idea what to make of this.

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