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Life Depends Upon the Liver

Life Depends Upon the Liver Let's face it. The price we surgeons pay is not just economic. That's what we mostly complain about. That's what you hear about, read about. But it's harder than that. Much harder. The real price is often physiologic and emotional. It goes to the human soul. I was 64 years old in 1990 when it hit me. I had been in surgery for 45 years, beginning as an operating room corpsperson, an operating room technician, in the US Navy in World War II. I used to boast about caring for war casualties; I must have been stuck by needles a thousand times. Nothing could hurt me. I was immune. I recall it was a Thursday, Thursday of a Labor Day weekend, and I wanted to get away early. I was driving north beyond the Golden Gate Bridge to spend the long weekend with my family at Lake Tahoe when the California Highway Patrol pulled me over and ticketed me for illegally driving in the commute lane. As I drove on afterward, having inconsolably and ineffectually exhausted all my excuses with the officer, I wondered if perhaps I was losing it. It was not like me to make such a stupid mistake, having traveled this same road hundreds of times. I had been inordinately tired for 3 months, I noted. But I had taken on night-and-day emergency department calls at 2 hospitals to defray the horrendous college tuition for 5 children. So what if I’d lost a little weight, couldn't sleep at night, and had no appetite. Fatigue is an episodic way of life with surgeons. Being tired was nothing new; it comes and goes with the territory. I had also noted a dark dysuria at times, mostly after my tennis game at a new club I had joined. So I ignored it; thought it was dehydration. September is the best month at Lake Tahoe. The place clears out a little, much of the heat of summer is gone, and when you arrive in the early evening the mellifluous pines greet you with open arms with their rare sense of coolness that faintly hints at the turning of the season. Robert Louis Stevenson, seeking surcease from tuberculosis, called it the most beautiful place on earth, nectar of the gods. Arrival at Lake Tahoe in September brings immediate balm, relief, a sense of quiet, and deserved rest. My wife said she had made dinner reservations for the two of us in the village. So, after noting the enviable berry brown health of my summer’s-end children, we escaped to dinner together. Relaxed, I ordered my usual Bacardi light rum on the rocks with a twist, and just as I was toasting another forthcoming fall, my wife looked me square in the eyes and suddenly exclaimed: “My God, you're jaundiced!” The light had hit her just right, and she saw me clearly. It was as if some great diagnostic poultice had been lifted from me to expose my essential self. And I replied simply, without hesitation, “I know I am.” That was the only way I knew to explain the way I felt. Wearing glasses, I could never visualize my own sclerae with sufficient detail. She had. And suddenly it all added up: the fatigue, the weight loss, the loss of appetite, and the concentrated dysuria. I had painless jaundice; there was nothing good it could be. Jaundice is always bad. I explained to her it likely meant 1 of 2 things: pancreatic cancer or hepatitis, neither good. She began to cry. We left without eating. I called my internist, who said there was no need to rush back to San Francisco because any laboratory work would not be returned until after the holiday. Why do these things always happen on holidays anyway? Why does medicine always seem to occur with chronic inconvenience, Grandma's gallbladder at Thanksgiving, a neighbor's child burned Christmas Eve? I took a long walk and began to think of what I had been through just 8 years previously. It was 1982, and we were seeing this strange new viral disease in San Francisco, a retrovirus that caused destruction of the immune system by infecting the system's cells that were supposed to be fighting infection. I was assisting a younger colleague one night with a gunshot injury of the abdomen. It had been a crash laparotomy at 3 AM with a lot of bleeding, and we were both exhausted. He was closing fascia with far-and-near through-and-through whip stitches using a large, solid-bore, curved, cutting edge needle when he got me at the base of my right thumb. The bleeding, the contamination, was gross. I dropped out and controlled it, then resumed helping him. I asked my friend if he knew the human immunodeficiency virus (HIV) status of the patient. He said he didn’t, but would run a test the next day. I got a call the following afternoon and was informed the patient was HIV positive. Mind you, this was at the beginning of the AIDS epidemic. Although San Francisco was at the forefront of this disease, we did not yet know its entire mode of transmission. Inter alia, we knew it was transmitted by needlesticks, but we didn't know what kind of needles. In other words, I didn't know, couldn't know then, as we later discovered, that HIV was transmitted only via open-bore needles. Panicked, prepared to die of a uniformly fatal disease, I didn't know what to do. There was no treatment then for “slim disease,” as it was known in Africa, so why should I tell anybody? If I tested positive, my professional life, my married life, would be history. Life would be over. My response was uncharacteristic, and I am not especially proud of how I handled myself. In the years that I taught residents, I emphasized what I thought was, and still think is, an important concept involving surgical judgment. Indeed, it's not a bad concept for handling the vagaries of life's many difficult problems as well. It is this: when you are confronted with an ambivalent and apparently insoluble urgent problem for which you are ultimately responsible, and when you have honestly added up all the pros and cons of the problem and there is simply no clear decision apparent to you or anyone else because it could go either way, do not be afraid to act in the direction in which you will learn the most. For even if that action turns out to be unrewarding, you will have contributed to the solution of the problem with your expertise. This attitude needs to be part and parcel of a practicing surgeon's disposition, because often under similar circumstances, people do nothing, avoid the problem, wait, and hope it will go away. But there it is, and there the problem smolders if nothing is done. Tomorrow is always better when we know the truth today, whatever that truth may be. I did not get an HIV test; I thought I would wait and see what happens. Do nothing. It occurred to me maybe that was what was happening to me now. AIDS. I was being punished. There are delayed cases, you know. A slow virus. It could easily happen 8 years later to me. The holiday weekend was passing too slowly for me. The hours seemed interminable. I needed to know something so I returned to San Francisco on Sunday. My internist said he would see me and examine me. I’d at least get a clinical appraisal. I took my 10-year-old son with me for company. We stopped for lunch in Corte Madeira, and he said: “Dad, with what you have in your liver maybe I shouldn't be eating with you. You are contagious! Does life depend upon the liver?” “Yes,” I said, “it also depends on how good you live, and I think you are a good liver.” He smiled and understood, understood much more just then than I did. It was Tuesday or Wednesday after Labor Day. I don't know which. There were more hours that seemed interminable. I went over my stock portfolio, went over my will. I told my wife over and over how much I loved her. Insomniac, would I be one of the 5% to 10% with pancreatic cancer at the time who survived a Whipple procedure for 5 years? Or would I be one of the 30% of operating room personnel who get hepatitis? There I was, waiting for results like all my patients with breast cancer had to do to find out if they had cancer, all my patients with colon cancer to see if they had positive nodes. I promised myself if I had the chance I would never be short with any patient again. I recall it was late in the afternoon. My wife was by my side. I love my sharp young internist and thought he would give me an answer straight off. But some young physicians don't do that any more. They don't give you your options accompanied by a recommendation as my generation did. Rightfully afraid of informed consent and malpractice and privacy laws, they give you your options and leave you to decide what you want. He wanted me to participate in the diagnosis. Thus, laboriously, he read the entire laboratory report to me and asked me to make the diagnosis. He read down to through all the electrolytes, my good and bad cholesterol levels, triglycerides, fasting blood glucose level, serum urea nitrogen level, creatinine level, glomerular filtration rate estimate, the coronary heart disease risk table, my prostate-specific antigen, the entire hemogram, and, finally, to the liver function test results. And all I remember was the alkaline phosphatase level was 61 U/L, the bilirubin level was 0.99 mg/dL (17 μmol/L), and the parenchymal liver test results were off the chart. It was not obstructive, it was infectious hepatitis. But I wanted him to say it to me, I wanted to hear it from him, the way a woman wants to be proposed to even if she knows what the answer is. He never did say it, but jocularly added, “Jim, FYI your HIV is negative.” My internist took good care of me. He put me to bed for 3 months and monitored my liver function test results. I thought I would die. Anorexic, I could only tolerate the breakfast that my wonderful wife walked up 3 flights of stairs to deliver every morning. The rest of the day I ate rock candy at his behest for its protein-sparing effect. I fell asleep after reading 1 page a day of the 200-page Life of General George Custer. I fought “The Battle of the Little Big Horn” and survived. I watched religious programs on television and was inspired by evangelist Dr Eugene Scott to reinvent my religious life. One day I found I could walk slowly around my San Francisco block. A week later, I walked up Fillmore Street to the drug store. My goal was limited. I wanted to get some Brylcreem for my overgrown and unruly hair. I had become reinterested in my own cosmesis. I paused at the store window, where I noted they had these new magazines with plastic covers showing glossy women. Standing there, staring, I recalled what Dr Samuel Johnson, the famous belles lettres literary icon of 18th-century England, said when asked to review the demimondaine of the Paris Follies: “The pretty pink bosoms of the young ladies excite my amorous propensities.” Suddenly, I knew I was better. For in illness our libido is first to go, and last to return. Thus, when it does twinkle in the night sky once more, however so little, it means you have crossed the Rubicon and are on your way. It took another 6 months to feel comfortable in surgery, another 4 in bed. All the while, I kept thinking, as my sage 10-year-old son said, “Life depends upon the liver.” Correspondence: Dr Neely, 23 S Newport Dr, Napa, CA 94559 (jcneely@pacbell.net). http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Life Depends Upon the Liver

Neely, James C.
Archives of Surgery , Volume 142 (6) – Jun 1, 2007
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Publisher
American Medical Association
Copyright
Copyright © 2007 American Medical Association. All Rights Reserved.
ISSN
0004-0010
DOI
10.1001/archsurg.142.6.503
pmid
17576884
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Abstract

Let's face it. The price we surgeons pay is not just economic. That's what we mostly complain about. That's what you hear about, read about. But it's harder than that. Much harder. The real price is often physiologic and emotional. It goes to the human soul. I was 64 years old in 1990 when it hit me. I had been in surgery for 45 years, beginning as an operating room corpsperson, an operating room technician, in the US Navy in World War II. I used to boast about caring for war casualties; I must have been stuck by needles a thousand times. Nothing could hurt me. I was immune. I recall it was a Thursday, Thursday of a Labor Day weekend, and I wanted to get away early. I was driving north beyond the Golden Gate Bridge to spend the long weekend with my family at Lake Tahoe when the California Highway Patrol pulled me over and ticketed me for illegally driving in the commute lane. As I drove on afterward, having inconsolably and ineffectually exhausted all my excuses with the officer, I wondered if perhaps I was losing it. It was not like me to make such a stupid mistake, having traveled this same road hundreds of times. I had been inordinately tired for 3 months, I noted. But I had taken on night-and-day emergency department calls at 2 hospitals to defray the horrendous college tuition for 5 children. So what if I’d lost a little weight, couldn't sleep at night, and had no appetite. Fatigue is an episodic way of life with surgeons. Being tired was nothing new; it comes and goes with the territory. I had also noted a dark dysuria at times, mostly after my tennis game at a new club I had joined. So I ignored it; thought it was dehydration. September is the best month at Lake Tahoe. The place clears out a little, much of the heat of summer is gone, and when you arrive in the early evening the mellifluous pines greet you with open arms with their rare sense of coolness that faintly hints at the turning of the season. Robert Louis Stevenson, seeking surcease from tuberculosis, called it the most beautiful place on earth, nectar of the gods. Arrival at Lake Tahoe in September brings immediate balm, relief, a sense of quiet, and deserved rest. My wife said she had made dinner reservations for the two of us in the village. So, after noting the enviable berry brown health of my summer’s-end children, we escaped to dinner together. Relaxed, I ordered my usual Bacardi light rum on the rocks with a twist, and just as I was toasting another forthcoming fall, my wife looked me square in the eyes and suddenly exclaimed: “My God, you're jaundiced!” The light had hit her just right, and she saw me clearly. It was as if some great diagnostic poultice had been lifted from me to expose my essential self. And I replied simply, without hesitation, “I know I am.” That was the only way I knew to explain the way I felt. Wearing glasses, I could never visualize my own sclerae with sufficient detail. She had. And suddenly it all added up: the fatigue, the weight loss, the loss of appetite, and the concentrated dysuria. I had painless jaundice; there was nothing good it could be. Jaundice is always bad. I explained to her it likely meant 1 of 2 things: pancreatic cancer or hepatitis, neither good. She began to cry. We left without eating. I called my internist, who said there was no need to rush back to San Francisco because any laboratory work would not be returned until after the holiday. Why do these things always happen on holidays anyway? Why does medicine always seem to occur with chronic inconvenience, Grandma's gallbladder at Thanksgiving, a neighbor's child burned Christmas Eve? I took a long walk and began to think of what I had been through just 8 years previously. It was 1982, and we were seeing this strange new viral disease in San Francisco, a retrovirus that caused destruction of the immune system by infecting the system's cells that were supposed to be fighting infection. I was assisting a younger colleague one night with a gunshot injury of the abdomen. It had been a crash laparotomy at 3 AM with a lot of bleeding, and we were both exhausted. He was closing fascia with far-and-near through-and-through whip stitches using a large, solid-bore, curved, cutting edge needle when he got me at the base of my right thumb. The bleeding, the contamination, was gross. I dropped out and controlled it, then resumed helping him. I asked my friend if he knew the human immunodeficiency virus (HIV) status of the patient. He said he didn’t, but would run a test the next day. I got a call the following afternoon and was informed the patient was HIV positive. Mind you, this was at the beginning of the AIDS epidemic. Although San Francisco was at the forefront of this disease, we did not yet know its entire mode of transmission. Inter alia, we knew it was transmitted by needlesticks, but we didn't know what kind of needles. In other words, I didn't know, couldn't know then, as we later discovered, that HIV was transmitted only via open-bore needles. Panicked, prepared to die of a uniformly fatal disease, I didn't know what to do. There was no treatment then for “slim disease,” as it was known in Africa, so why should I tell anybody? If I tested positive, my professional life, my married life, would be history. Life would be over. My response was uncharacteristic, and I am not especially proud of how I handled myself. In the years that I taught residents, I emphasized what I thought was, and still think is, an important concept involving surgical judgment. Indeed, it's not a bad concept for handling the vagaries of life's many difficult problems as well. It is this: when you are confronted with an ambivalent and apparently insoluble urgent problem for which you are ultimately responsible, and when you have honestly added up all the pros and cons of the problem and there is simply no clear decision apparent to you or anyone else because it could go either way, do not be afraid to act in the direction in which you will learn the most. For even if that action turns out to be unrewarding, you will have contributed to the solution of the problem with your expertise. This attitude needs to be part and parcel of a practicing surgeon's disposition, because often under similar circumstances, people do nothing, avoid the problem, wait, and hope it will go away. But there it is, and there the problem smolders if nothing is done. Tomorrow is always better when we know the truth today, whatever that truth may be. I did not get an HIV test; I thought I would wait and see what happens. Do nothing. It occurred to me maybe that was what was happening to me now. AIDS. I was being punished. There are delayed cases, you know. A slow virus. It could easily happen 8 years later to me. The holiday weekend was passing too slowly for me. The hours seemed interminable. I needed to know something so I returned to San Francisco on Sunday. My internist said he would see me and examine me. I’d at least get a clinical appraisal. I took my 10-year-old son with me for company. We stopped for lunch in Corte Madeira, and he said: “Dad, with what you have in your liver maybe I shouldn't be eating with you. You are contagious! Does life depend upon the liver?” “Yes,” I said, “it also depends on how good you live, and I think you are a good liver.” He smiled and understood, understood much more just then than I did. It was Tuesday or Wednesday after Labor Day. I don't know which. There were more hours that seemed interminable. I went over my stock portfolio, went over my will. I told my wife over and over how much I loved her. Insomniac, would I be one of the 5% to 10% with pancreatic cancer at the time who survived a Whipple procedure for 5 years? Or would I be one of the 30% of operating room personnel who get hepatitis? There I was, waiting for results like all my patients with breast cancer had to do to find out if they had cancer, all my patients with colon cancer to see if they had positive nodes. I promised myself if I had the chance I would never be short with any patient again. I recall it was late in the afternoon. My wife was by my side. I love my sharp young internist and thought he would give me an answer straight off. But some young physicians don't do that any more. They don't give you your options accompanied by a recommendation as my generation did. Rightfully afraid of informed consent and malpractice and privacy laws, they give you your options and leave you to decide what you want. He wanted me to participate in the diagnosis. Thus, laboriously, he read the entire laboratory report to me and asked me to make the diagnosis. He read down to through all the electrolytes, my good and bad cholesterol levels, triglycerides, fasting blood glucose level, serum urea nitrogen level, creatinine level, glomerular filtration rate estimate, the coronary heart disease risk table, my prostate-specific antigen, the entire hemogram, and, finally, to the liver function test results. And all I remember was the alkaline phosphatase level was 61 U/L, the bilirubin level was 0.99 mg/dL (17 μmol/L), and the parenchymal liver test results were off the chart. It was not obstructive, it was infectious hepatitis. But I wanted him to say it to me, I wanted to hear it from him, the way a woman wants to be proposed to even if she knows what the answer is. He never did say it, but jocularly added, “Jim, FYI your HIV is negative.” My internist took good care of me. He put me to bed for 3 months and monitored my liver function test results. I thought I would die. Anorexic, I could only tolerate the breakfast that my wonderful wife walked up 3 flights of stairs to deliver every morning. The rest of the day I ate rock candy at his behest for its protein-sparing effect. I fell asleep after reading 1 page a day of the 200-page Life of General George Custer. I fought “The Battle of the Little Big Horn” and survived. I watched religious programs on television and was inspired by evangelist Dr Eugene Scott to reinvent my religious life. One day I found I could walk slowly around my San Francisco block. A week later, I walked up Fillmore Street to the drug store. My goal was limited. I wanted to get some Brylcreem for my overgrown and unruly hair. I had become reinterested in my own cosmesis. I paused at the store window, where I noted they had these new magazines with plastic covers showing glossy women. Standing there, staring, I recalled what Dr Samuel Johnson, the famous belles lettres literary icon of 18th-century England, said when asked to review the demimondaine of the Paris Follies: “The pretty pink bosoms of the young ladies excite my amorous propensities.” Suddenly, I knew I was better. For in illness our libido is first to go, and last to return. Thus, when it does twinkle in the night sky once more, however so little, it means you have crossed the Rubicon and are on your way. It took another 6 months to feel comfortable in surgery, another 4 in bed. All the while, I kept thinking, as my sage 10-year-old son said, “Life depends upon the liver.” Correspondence: Dr Neely, 23 S Newport Dr, Napa, CA 94559 (jcneely@pacbell.net).

Journal

Archives of Surgery – American Medical Association

Published: Jun 1, 2007

There are no references for this article.