A Lesson in Pallative Care

~Warning- some pictures in the following post may be considered graphic~

When you really enjoy what you do for a living it doesn’t always feel like a job. Sure, the early mornings can be killer and there are some days that you just wish you could go home and never come back. But if you have a real passion for your work the majority of your days are filled with a sense of accomplishment and pride.

Being a surgical tech is one of the most rewarding things I’ve ever done. It’s not glamorous and it’s not full of recognition. But every day I know I helped make a difference in someone’s life. Maybe I helped relieve their pain. Maybe I assisted in giving them back their range of motion so now they can play with their grandchildren. Or perhaps I helped perform an emergency surgery that saved their life. The patient often has no idea who we are and the only part of our face they see is from the eyes up. But that’s okay because when they wake up from their surgery they can hopefully look at the faces of the people they love and know that they’re going to be just fine.

Sadly though, that’s not always the case. Sometimes we can't cure what ails them. And the only thing left for us to do is to try to improve their quality of life and give them the most pain-free time we can give them.  This is called palliative care.

 I first heard of this back a few years ago when my grandfather suddenly got sick. My family and I waited for days in the hospital waiting room praying that the doctors would be able to give us good news. But it never came. We had two options. Keep him on life support or realize that he lived a full life and let him pass away peacefully with no pain. I can tell you that it was the hardest decision our family has ever had to make. You never want think that there is no more hope. You never want to give up because what if……..but we knew it was the right thing to do.

What television and movies don’t tell you is that when you take a person off a ventilator they don’t die instantly. By any means. So the doctors told us that they were going to move my grandfather to the palliative care floor. There he would be given a practically endless supply of pain medication and they would simply continue to care for him but no live saving measures would be a part of his care. It was the right choice.

In surgery palliative care means that we perform a surgery or surgeries that will alleviate a patient’s pain or will give them a better quality of life until they die. We can’t cure whatever is wrong with them, usually cancer. When you find out that you’re performing a palliative procedure on a patient, your heart sinks because you’re used to fixing people. The prognosis is usually good. But in these cases you know better.

Recently, I had a patient coming in for an exploratory laparotomy. This means that we make a long midline incision in the patient’s abdomen to expose the bowel.

Then we basically look around (not always knowing what we’re looking for) and try to find the source of the problem. For this patient it was gastrointestinal cancer.  In this case the cancer had metastasized to other organs and there was nothing else that could be done to cure it. The patient had already had a partial gastrectomy (removal of part of the stomach) but the original tumor was in her bowel and had grown large enough to cause an obstruction (blockage) and was causing her considerable pain.

Once we located the tumor (which turned out not to be too hard…it was the size of a softball) it was just a matter of deciding how best to proceed. 

The surgeon decided that the best outcome would come from a Roux-en-Y procedure. This is named after the surgeon who developed it, Cesar Roux, and the way the final product looks (the letter Y).

After clamping the bowel on both sides of the tumor we used a stapler to both close the bowel and cut it.

Bowel surgery is very delicate because the contents of the bowel are highly contaminated with bacteria and it’s very important that we don’t let it spill out into the abdominal cavity. Once both sides had been stapled shut and were cut we were able to remove the diseased portion with the tumor. Then it was just a matter of reconnecting the remaining portions of the bowel to what remained to her stomach and to each other.

All in all the surgery took about four hours to complete. It wasn’t easy and to be honest, I wasn’t entirely sure I was ready to scrub on it by myself but I tend to underestimate myself and did just fine. As a team we did exactly what we set out to do. We took out the source of our patient’s pain and gave her a little more time to spend with her family. That’s all we could do. But at least we did something.

Take the Good With the Bad

I’m going to start this post on my soapbox. Feel free to skip down a couple of paragraphs if you’d rather not hear it. But I feel like as a medical professional I have a duty to educate and warn people of the dangers of smoking. Since smoking ties into this post, I’m going to do it now.

Now it’s no secret that smoking is bad for you. We’ve known it for years. It even tells you directly on the package. However most people think that all those warnings and dangers are greatly exaggerated. I’m here to tell you that they are not. I’ve seen the damage that smoking does to a person’s body and it is NOT pretty! Here are some fun facts that I found at quittersguide.com:

90% of lung cancer cases are caused by smoking.

30% of all cancer fatalities are caused by smoking.

Lung cancer is the most common cancer associated with cigarette smoking but you can also get cancer of the mouth, bladder, kidney, stomach, esophagus, larynx and pancreas. Some of these cancers can be treated and others are 100% fatal.

Cancer isn't the only disease that smoking causes - either directly or indirectly. 75% of all fatal cases of emphysema and bronchitis are linked to smoking. Both of these diseases cause extreme breathing difficulties and emphysema in particular is an extremely nasty disease as your ability to breathe on your own slowly vanishes.

Smokers have dramatically shorter lives than non-smokers. On average a smoker will die 15 - 20 years before a non-smoker. This is truly shocking when you think about it. That's 7,300 days deducted from your lifespan. Look at what you can achieve in a single day and then imagine what you might be able to achieve in over 7,000 days.

Okay, I’m done with the lecture. On with the show.

The other day I started my rotation in ENT (ear, nose, and throat) surgery. To be honest, I wasn’t very enthused about it because in my little experience I found it to be a little on the boring side but also kind of difficult because there are thousands (okay that may be a slight exaggeration) of specialty instruments. But I want to be able to do as many surgical services as I can so I was determined to master ENT.

The bread and butter of ENT surgery is myringotomys (insertion of ear tubes to assist in the drainage of fluid) and T&A’s (removal of the tonsils and adenoids). Both of these procedures take less than twenty minutes and are not considered sterile procedures. These are called “clean” procedures. The instruments and equipment are sterile and we wear our sterile gown and gloves but the mouth and ears are not sterile areas of the body so our sterile technique is more relaxed.

So I thought that a day in ENT would be more stress free than what I was used to. And if it had just been ear tubes and tonsils I would have been right. But nestled right in the middle of my day full of children with chronic ear infections and sore throats was a man with a tumor running down the entire left side of his throat. This is where my day turned really, really bad.

The patient was a 44 year old male who smoked at least a pack and a half a day. The cigarettes had really taken a toll on his body. Like I said, he was in his forties but he looked easily sixty or seventy. His skin had aged prematurely.  His teeth and fingers were stained with nicotine and he had a chronic cough. He also had trouble breathing due to the enormous tumor in his throat. We didn’t know yet if the tumor was benign (not cancerous) or malignant (cancerous) but we suspected it was cancer caused by his many years of smoking. The tumor was growing and the bigger is grew, the less he could breathe.

The plan for him was to snake a scope in his mouth and down his throat so we could do only get a good look at his tumor but to also take a biopsy of it to send to pathology so we would know what we were dealing with. In addition, if we felt it was necessary once we got a good look at the tumor we were prepared to perform a tracheotomy. The patient wasn’t thrilled with this possibility but the surgeon had told him on numerous occasions that it was just a matter of time before we had to do it anyway.

 A tracheotomy (also referred to as pharyngotomy, laryngotomy, and tracheostomy) consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea. The resulting stoma can serve independently as an airway or as a site for a tracheostomy tube to be inserted; this tube allows a person to breathe without the use of his or her nose or mouth. Both surgical and percutaneous techniques are widely used in current surgical practice.

I had never done a trach before so another nurse came into the room to assist. And it was just my luck that it was the one person I’ve come across in the hospital that I’m not fond of. This woman always has a bad attitude, her words just drip with sarcasm, and it seems her sole job is to point out everything I do wrong. Yay!

We never even got to the scope part of the procedure. When the anesthesia provider tried to intubate the patient, she ran into a huge problem. The throat tissue was so friable (easily broken into smaller pieces) that wherever the breathing tube touched fell apart and started to bleed. It also caused the throat to swell.

Our patient wasn’t getting any oxygen. Normal O2 (oxygen) stats are between 95-100%. His stats quickly fell to 80 and continued to drop. We needed to trach him and very fast. This is where things in the OR get scary. The surgeon quickly went to work.

There were three of us scrubbed in so there wasn’t too much for me to do but I was ready and willing to help out in any way I could. So every now and then when that favorite (or not) nurse was busy I would hand up an instrument or two as they were needed. But because of the state of the patient’s throat the doctor was having a very hard time getting the tube in. As a matter of fact, even he was starting to panic and told the nurse to run out to the desk and find ANY available surgeon to come in and assist. The patient’s O2 stats fell to 20%. This is when brain cells start to die. NOT GOOD!

There is one instrument that is crucial in this procedure. It’s the trach hook. You can’t do a trach without one. So when the surgeon looked at me and asked for the hook I reached on the mayo stand and picked it up with no hesitation and was ready to pass it…..

Until that fantastic (or not) nurse tried to grab it out of my hand. When she did she pushed the hook through my glove making the most important instrument contaminated. Our patient was in danger of coding and the one hook we had was now hanging off my hand. She started cursing and yelling. I stood there not knowing what to do. The surgeon (who is fantastic by the way) asked if it had cut me. I told him no that it had just puncture my glove. So he grabbed it and quickly completed the trach. At this point, the fact that he could have introduced any resident bacteria that was on my hand was the least of his worries.



After about five minutes of trying he finally got the trach in and it was hooked up to oxygen. His O2 stats finally started to rise and we were out of the woods. By this time though, I was so shaken that I broke scrub and just stood in the back of the room trying not to cry. I was just beating myself up. Why didn't I just stand out of the way? Why did I even scrub? Why didn't I just let that great (or not) nurse do all the work while I just stood there? I mean, in my head I could have been the cause of that man dying. Let me be the first to tell you that it's not a great feeling.

After the patient stabilized they ran the scope down his throat and did the biopsy as planned. We sent the specimen down to pathology and waited patiently as they examined it. They called into the room with their diagnosis- squamous cell carcinoma. Throat cancer.

After the case was finished the surgeon came up to me to ask if I was okay. I told him I was, just a little shaken. He pulled me aside and told me that I had done everything right. He asked me for the hook because the other nurse had solely decided that I didn't need to learn how to do one of those cases and that just wasn't the way it should work. It wasn't my fault and that I shouldn't take it so hard. Thank God for nice doctors!

I learned a lot that day. I learned that not everyday is going to be fun and that there will be days when I feel like all I did was mess up. But tomorrow's another day. And another day brings more cool surgeries.