Spare Parts: First Cuts are Deepest

Part 3 (start here for the beginning)

…seven weeks have passed. Just enough time to get my mind off the whole transplant thing and then it happens. I’m standing in the middle of my Emergency Department after I just delivered a lecture (Neuro Exams: It’s not brain surgery) in our hospital-based critical care course. I dressed for the occasion and look oh so professorial in a Brooks Brothers charcoal gray suit and paisley maroon bow tie. Chatting up my co-workers while getting ribbed for suiting up, I suddenly realize that my beeper, my transplant beeper, is beeping. I immediately call and get a similar message to the one from two months ago — “we’ve got a near perfect match pancreas. Can you get here in the next two hours?”. I give a “yes” and call my wife. Amy tells me not to worry. She’ll follow as soon as she can make arrangements.

Getting to the hospital quickly is challenging. I’m facing afternoon rush hour and I’m 80 miles away. Nevertheless, I make it 90 minutes. I accomplish this with vehicular maneuvers that threaten to make me an organ donor not a recipient. I’m met by a transplant coordinator walking into the lobby. She informs me we have to hurry. The pancreas is here, the OR is on hold, all they need is me. She drags me by the arm to a secret elevator and we ascend several floors. The doors open and I step out into the core of OR suites.

An OR nurse takes me from there to OR #10. Bow tie, wingtips and all, I enter the brightly lit room. I’m greeted by a warm, smiling, robust woman. She introduces herself as my “personal gas passer”. She explains her plan and I sign consent for anesthesia. Suddenly, I’m feeling a little shy when I realize I’m standing there in my undies. I’ve gone from nursing-subject expert to vulnerable, frail patient in two minutes flat. My gas passing buddy expertly places a 16 gauge harpoon into my vein as I lay on the table. A little midazolam is injected to settle my nerves. She follows this with Etomidate which gives me the sensation of folding inward upon myself from the tips of my extremities towards my core. Strange as it sounds, I feel an overwhelming peace as I check out for a while.

I awake in a complete fog in the Post Anesthesia Care Unit (PACU) seven hours later. A warm, tender kiss from Amy starts to clear my head. A cough rouses me like noontime Sun from the pain I feel in my abdomen. The pain confirms I now have at least one box to check under Past Surgical History. Amy validates this saying, “Everything went great! You have your new pancreas!”. My nurse promptly gives me some Fentanyl and, being the lightweight that I am, I go right back to Dreamland.

I’m completely disoriented many hours later when I slowly come back to Earth. My eyelids are so heavy. I can hear beeping and alarms that make me think I’m at work. There is a conversation occurring over top of me:

Voice 1: “ It says his sugar is 156.”

Voice 2: “Uh oh! His last one was 99?”

Voice 1: “Isn’t he getting steroids?”

Voice 2: “Yeah, that’s probably it.”

My eyes open wide and Voice 2 says “Look who’s awake! How are you doing? My name is Sandy and I’m your nurse. You’re in the Surgical Intensive Care Unit (SICU). You’re doing great!” This surprises me because I feel like a train hit me. My belly still hurts but there’s a pain of infinitely greater intensity in my left shoulder. I tell Sandy about this and she orients me to my patient-controlled analgesia (PCA) pump. One hit of the button squirts a little Fentanyl into my IV line. A 10 minute “lockout” keeps me from overdosing. I nod that I understand then push the button. 20 minutes and 2 hits later the pain is down from excruciating to gnawing.

Two hours pass and a nursing assistant shows up to check my blood glucose. “Hmm” she says following the beep that means a value is displayed. “What is it?”, I ask her. She hesitates and says “247”. I tensely reply, “Go get my nurse!” The Fentanyl is no longer having an effect on my shoulder pain. It feels like someone is slowly driving a screwdriver into my joint. I’m filled with a sense of doom — I’m so scared! Sandy responds promptly and immediately lessens the fear. She reminds me that large dose steroids are part of my medication regimen and the most likely suspect causing a transient rise in blood glucose values. “This pain is nuts though”, I tell her. She informs me the SICU team is rounding on the unit and they’re coming to me next.

A mob of whitecoats appear at my door. The one closest in age and looks to Doogie Howser, MD starts report:

Adam is a 25 year old male status post Panc[reas] alone transplant; this is post-op Day 1. OR case was uncomplicated, he was extubated prior to PACU transfer. He’s on 2 liters O2 via nasal cannula. The nursing staff have implemented incentive spirometry but patient compliance is intermittent probably due to pain control issues. Vital signs are stable. A Fentanyl PCA is in use at 0/12.5/10 (a zero infusion rate, 12.5mcg per push dose, 10 minute lockout). PCA Attempt to Delivery is 3:1.

Doogie gets through my current glucose issues then gets stopped by the graying Intensivist leading rounds. The man approaches my bedside and, with a Southern drawl, says, “How ya doing. I’m Dr Jorgenson and I’m holding the reins of this mule team”. His charm is lost on me as I reply “Doc, something is wrong! My shoulder is killing me. I’ve never had this much pain!” He glances at the monitor and asks me, “Are you winded?” I shake my head no. He listens to my chest with his stethoscope. The deep breaths he asks me to take temporarily transfers the most intense pain to my abdomen. He looks to the doorway and calls over Doogie. He says, “Did you say his vital signs are stable? What’s his heart rate?” A sheepish Doogie glances at the monitor and replies “120”.

Doc: “What’s his pressure?”

Doogie: “90 over 54”

Doc: “His respirations?”

Doogie: “22”

Doc: “Which one of these signs do you consider stable?”

Jorgenson invites the rest of the group into the room and asks, “Team, what do we need to worry about given what we know right now?” “PE” (Pulmonary Embolism) responds one resident. Another says, “Pneumonia, he wasn’t NPO (fasting) prior to surgery. Maybe he aspirated.” Jorgenson responds, “Listen, those are both valid but y’all not putting it together! Tachycardia, downward trending BP, uprising glucose in the face of severe left  R-E-F-E-R-R-E-D shoulder pain tells us we have what kinda problem in this post-pancreatic transplant patient?” He turns on his heels when I say, “A pancreas problem. I have pancreatitis,” He turns back to the team and says, “Get me Transplant and an ultrasound now!” He instructs Sandy to draw labs, hang a litter of saline and give me an extra dose of Fentanyl. He looks back at me and says, “We’ve got some work to do but tell Sandy if you need me.”

The Transplant attending and the ultrasonagrapher arrive at the same time. The surgeon does a brief exam and, though he thinks it’s imperceptible, I clearly read his non-verbal concern. He stands by as the ultrasound probe is applied to my tender belly. It doesn’t take long to get the information he needs. The surgeon looks at me and says, “There’s no arterial flow to the transplanted pancreas. You have a thrombus (clot) in the grafted artery. You’re going back to the OR!” “Can you fix it?”, I ask desperately. His sterile reply “No, it’s already dead. We’ve got to get it out.”

The transplant surgeon stops by the next day. He explains, “We basically had to take it out with an ice cream scooper. It literally fell apart in our hands. Several other areas showed evidence of injury including your native pancreas. We did a thorough washout but we’ll need to keep a close eye on you.” I spend the next week in the SICU then get transferred to the floor. Amy and I meet with the transplant team just prior to discharge. They inform me that I remain on the list but I’ll need to wait at least six months in order to heal. The decision to continue this path is mine to make. I tell them I need time but instruct them not to change my status.

Eleven months later, I’m lying on an OR table back on the Transplant Service…

 

6 thoughts on “Spare Parts: First Cuts are Deepest

  1. Oh what a lot to have gone through only to have it fail. Is it worse to have your level of knowledge? Are you o..k.? Did a blood clot cause the pancreas to fail? You are in my prayers.

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    1. The clot was the culprit. It was very difficult to be deep in the know of all that was happening. In other ways, I attribute these events in making me a different kind of nurse, husband, father, son, friend, etc. I’ll draw this out in the final post of this series. Thanks so much for the love and support!

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  2. Fascinating yet gut-wrenching story, as are most things in medicine. I’ve never been on the patient side, but I’m sure this experience has really influenced (humbled?) your practice. Looking forward to reading your final post!

    Liked by 1 person

  3. I’ve known you for so long (not as long ago as this!) and never known the story of how it all happened! I love that you’re putting it out for the world to know!

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