I have often thought about writing a book, a combination of a memoir and opinion about health care in general with emphasis on women. It would not be a regurgitation of the ever-changing evidence but rather putting anatomy, physiology and evidence in context.
I truly have a love/hate relationship with evidence based practice of medicine in general and in particular the clinical algorithms that are used as recipe cards rather than guidance to make good decisions for the individual patient in front of you. Over the past decade, I have had the opportunity to be at the beside of 5 family members who were in the hospital – 4 of the experiences are very illustrative of poor care – 2 with very bad outcomes.
My most recent exposure to the inadequacy of using clinical algorithms rather than looking at the patient occurred 3 months ago. A extremely health young women enters an academic medical center for a major pelvic surgery. She knew there may be significant blood loss but was prepared for one or two nights in the hospital. She spent 2 weeks in the hospital – at least one week was totally unnecessary.
As a urologist, I prepared her for having a catheter draining her bladder after the surgery until she was able to get up and and get to the bathroom. The catheter is necessary during surgery to keep the bladder from filling up and getting in the way of the surgery. Keeping track of the urine output is a vital sign during surgery particularly when there is significant blood loss. During the surgery, a lot of fluids are given through the veins to replace the blood that is lost. For a day or so after surgery, the kidneys are getting rid of the excess fluid. I WAS SHOCKED when I found out the surgeon had removed the catheter in the operating room when the procedure was over. Not only was the bladder going to be filling up while she was in the recovery room without access to the bathroom, but they had no way of monitoring her urine output to help determine if she was high or low in fluids after the surgery.
She had a fair amount of pain following the procedure and was in the recovery room for several hours. Predictably, her bladder was full and she was not able to empty it until she got to a room. Her bladder had twice the normal amount it in when she was able to empty it. Fortunately her bladder function seems fine.
Why was there a rush to remove the catheter. There are clinical care pathways that mandate that catheters be left in as short a time as possible to prevent bladder infections. The risk of bladder infections increases after the catheter is in 2-3 DAYS, not hours. In the context of a simple operation where there is not significant blood loss and you are not expecting the patient to have a lot of pain, it would be reasonable to remove the catheter at the end of the procedure for patient comfort.
HOWEVER, in this circumstance, it was a BAD decision and I was on high alert for subsequent decision making based on algorithms and evidence without taking the context of the patient into account. I wish I could say I was wrong about that.
She not only lost a significant amount of blood during surgery but after surgery as well. She was young and her pulse rate and blood pressure were OK. They gave her very little fluid through her vein because there is some evidence to suggest that too many fluids can delay return of bowel function. Her hemoglobin (amount of red blood cells that carry oxygen) was 7.1. The guidelines say you do not transfuse unless the hemoglobin is 7.0 or below. While she was able to get out of bed to use the toilet, she did not have the strength to walk. So they kept drawing blood and not transfusing her. Finally by the end of the second day after surgery when she still did not have energy to walk, she received a blood transfusion.
In the context of a gradual blood loss where the person has a chance to adjust to fewer red blood cells to carry oxygen, holding transfusion until the hemoglobin is at 7 or below may make sense, but in the context of a major operation where the blood loss is rapid and the most important thing in the recovery period to prevent pneumonia, blood clots in the legs and delayed return of bowel function is walking a hemoglobin of 7.1 AND not having the strength to walk should be an indication for a transfusion.
In the context of 2 precious days without walking, delay of bowel function (ileus) would be predictable. She was also very nauseous which is not typical of ileus. While there were some signs that her bowels were “waking up” (passing small amounts of gas), on the morning of the 3rd day after surgery, she vomited 2 quarts of fluids that had not passed through the intestines. This is highly unlikely with just an ileus (paralysis).
I immediately said she has a partial small bowel obstruction. The doctors taking care of her said they didn’t really manipulate her intestines during the surgery so she has no reason to have an obstruction and recommended that she not have anything to eat or drink. After vomiting that much, she felt much better and by the next day drank a bit of fluids and the next day had a bit to eat. She passed some gas and even had a small bowel movement. I would have been so happy to have been wrong – except that I wasn’t.
What were the doctors missing? They were missing that she could have ileus (paralysis) and a partial obstruction at the same time. As the ileus was resolving the intestine below the obstruction were working and she was passing gas and small bowel movements. After she initially vomited the large volume it took another 3 days for the intestines and stomach to fill up again. It is HIGHLY unusual to vomit that much with just paralysis.
On the 6th day after surgery she vomited again. A CAT scan showed she had a partial small bowel obstruction. A nasogastric tube needed to be placed through her nostril, down the back of her throat, into her stomach to drain all of the fluids that were not passing through. The general surgeons were consulted and they recommended to continue the nasogastric drainage until there was evidence that the fluid was moving through. The first day, 4 quarts were sucked out of her stomach and each day it got a little bit less. The surgeons recommended a X-ray to try to locate the level of the obstruction which turned into a nightmare all of its own which I will not bore you with.
Now she had gone a week without nutrition so she needed to have a special IV placed so she could get nutrition through her veins. Poor nutrition can increase the fluid in the wall of the intestines which can contribute to the obstruction.
The nasogastric tube was torture every second until it was removed after 5 days. She slowly started drinking and eating and enough was getting though. the obstruction that she did not vomit. She was able to go home 2 weeks after the surgery. Her first night home, she had an episode of severe abdominal pain. She likely ate a bit too much and it temporarily blocked the bowels again. Fortunately, it moved through and she modified her eating to avoid the pain. The obstruction was open enough but not gone.
We still do not know what the cause of the obstruction was. Unfortunately, it can recur. Earlier this week, almost exactly 3 months after surgery, she had another episode of severe pain. She paced and it passed.
I still have PTSD from this experience. It was activated earlier this week when I heard about the episode of pain. Thank goodness it resolved pretty quickly and hopefully this will not be a chronic problem.
I trained before the era where clinical algorithms and “evidence” take precedence over what the individual patient “is telling your” through words and actions, supplemented by blood tests and images. In this case, would giving her a transfusion on the first day after surgery prevented the small bowel obstruction? I am not sure. However, I am positive, that if the small bowel obstruction had been recognized when she first vomited her hospital stay would have been one week rather than two. She would have not needed the IV nutrition. The doctors saw what they thought should be happening, not what was happening.
Writing this is a bit therapeutic for me, but is there value to anyone else? I often think it would be better to not have the medical knowledge so you can simply believe you are getting the best care. In this experience and unfortunately several others, knowing what should be done without the power to do anything about it, doesn’t change anything.
Tamara Unleashed 