Thursday, April 24, 2008


I knew before even laying my eyes on the bowel, that this patient was headed for the morgue. I could smell it.

As we divided the muscle and fascia below the skin, that sickening stench of death escaped from her abdominal cavity and filled the room. I immediately suppressed a gag, and blinked my eyes as they teared up from that acrid stench.

Sure enough, when the abdomen was opened, we could see that nearly the entire length of her small intestine had turned the color of rot: black, green, yellow, and gray.

It was easy to figure out what had happened. After this patient's heart attack two days ago, a portion of her heart muscle died and the heart developed an irregular rhythm. This completely changed the fluid dynamics within the chambers of the heart, creating small eddies where blood would slow down and coagulate. This consequently developed small blood clots, and one of these clots had made it out of her heart, down her aorta, and got dislodged in the main artery supplying her small intestine, completely blocking any further blood flow past that clot.

And with that blockage, the cells in her intestines suffocated from the lack of oxygen and died within several hours. And much like how shrimp kept in a warm room will quickly rot, so did her intestines. Within the warm cavity of her abdomen, kept at a stable 98.6 degrees, the bacteria in her intestines quickly grew and started eating away. She was literally rotting from the inside-out.

We could remove the rotten small intestine, that wasn't the problem. The problem was that she would have been left with less than 8 inches of small intestine. Anything less than 36 inches is incompatible with life. Without the ability to absorb any nutrients from what she ate, she would simply starve to death... assuming she even survived this operation.

Remove the rotten intestine, she dies. Leave the intestine in, she dies. A lose-lose situation.

The resident across the table from me looked up, "Close?"

I nodded my head. There was nothing to be done. The best thing for her at this point was to close that incision and take her back to the ICU so that her family could be with her the last hours of her life.

I stepped away from the operating table, pulled off my gown, and went to the phone to call the attending surgeon to tell him of the findings.