episode_0149

Episode 149. Appendicitis (1)

****

Boom! With a loud crash, Amy burst through the lab door.

It happened often. I looked up at Amy. Amy took a deep breath and opened her mouth.

“An emergency patient has arrived!”

“What kind of patient is this?”

“I have severe lower abdominal pain, bloody diarrhea, and increased respiratory rate and body temperature. I came here in a hurry because I thought it was cholera.”

“Have you tried pressing the belly button?”

“No.”

“I need to see where it hurts.”

I packed my bags and left the lab. Amy was stamping her feet in a hurry.

“Let’s go. Why did you think it was cholera?”

“Diarrhea and fever.”

“Have you ever been in contact with a cholera patient?”

“There wasn’t any. But you might not know that.”

I nodded. It didn’t seem like cholera. Cholera didn’t seem to cause severe abdominal pain and bloody diarrhea.

That doesn’t mean it can’t happen, but it usually doesn’t. Severe abdominal pain and bleeding seem more consistent with appendicitis or colitis.

Let’s go and see.

“How old is the patient?”

“33 years old, male. Farmer living near the capital. I can’t find the reason for my current illness. The only unusual thing is that I sweat a lot.”

I thought about it for a moment.

I hope it’s not appendicitis. Surgery for appendicitis is relatively simple, but I don’t know how to do surgery for diverticulitis. They may have to cut the intestines and reattach them…

It’s not an easy task. I don’t think it’s the right age for me to get gastritis yet.

If it’s cholera, as Amy said, it can be treated with oral rehydration and, if necessary, antibiotics. That’s easier.

“Did you see the patient’s pulse or something?”

“Uh, the patient’s pulse was 130/min. It was a bit fast. There were no signs of dehydration yet.”

Look, if it was cholera, there wouldn’t have been any other symptoms before dehydration.

I sighed.

“How have you been coping?”

“First, I gave him salt water. I heard that giving aspirin to patients with gastric bleeding could be a big problem, so I gave him a small amount of opium.”

“Good job.”

Of course, if it were a modern hospital, they wouldn’t have given out opioid painkillers so liberally. There weren’t many options available here.

“They’re all here.”

“I was worried that you might die because you looked so sick. But I feel relieved when you come, Professor.”

The ward was a bit chaotic because of the screaming patient. I went into the room.

You seem to be in a lot of pain.

****

I looked at the patient lying in the hospital bed. The first thing that caught my eye was the bed drenched in cold sweat. He was still sweating.

They said he had a bit of a fever. His complexion wasn’t very good, but his eyes and mouth didn’t show any signs of dehydration. It seemed like the nurses had been diligently giving him water.

“Patient. Are you awake?”

“Yes?”

“How much does your stomach hurt right now? If 10 is the most painful and 0 is the least painful.”

“Oh, about 5. It was 7 before.”

Well, since you said you took opium, the pain you feel now might not be that bad.

“I’ll take care of it for you. First, I’ll examine your abdomen. Even if it’s uncomfortable, please bear with it for a moment… … .”

I lifted the patient’s top to expose her belly button and motioned for Amy to come over. Amy followed right over.

“Yes.”

“Look. Do you know where the appendix is?”

“Uh, bottom right?”

I nodded.

“That’s right. If you feel the point where the navel and the anterior iliac spine, the third point where the sacrum protrudes, you can find the exact location of the appendix. That should be around here.”

I felt the patient’s bony prominence and her navel with my hands, then I felt the point where the thirds were roughly divided with my fingers. Halfway between the navel and the bony prominence, and slightly below that.

In medical terms, it is called McBurney’s point.

The point in the abdomen where the appendix is anatomically located. I pressed hard on the patient’s McBurney point, and the patient flinched.

“Does it hurt when you press here?”

“Yes.”

“Where else?”

Based on the diarrhea and bleeding, let’s assume there is a problem somewhere in the large intestine.

I pressed the patient’s stomach along the path of the colon. The patient let out a small moan.

“Where does it hurt the most?”

“Where you first pressed.”

“Here?”

I pressed my finger on the McBurney point again, and the patient screamed again. I guess it’s appendicitis…

****

In modern hospitals, appendicitis is usually diagnosed with CT scans, ultrasound, and blood tests. There is no such thing here.

I know it’s most likely appendicitis.

Can I go into surgery just for this? If I’m lucky, it might be resolved with antibiotics.

“Amy. Should I get this surgery or not?”

“Do you need surgery?”

“If it’s appendicitis, removing the appendix is the best method. But if you’re lucky, it might be treated with antibiotics… … .”

Amy tilted her head.

“Then wouldn’t it be better to have surgery?”

The patient’s body temperature rose to 38 degrees. It might be better to perform surgery quickly…

****

We moved the patient to the operating table. Appendicitis surgery is a relatively simple operation.

All you have to do is open the McBurney branch I mentioned earlier, go into the abdominal cavity, and remove the appendix.

Of course, there are endless things that can go wrong.

Once you open it and go in, it might not be appendicitis. If that happens, it’s a big problem. Not only did you open the stomach for no reason, but it also means that there’s no clear solution to the problem.

“Look closely, Amy. I’m going to make the incision minimal, and I’m going to draw the incision line including the McBurney point where you said the appendix was.”

“Okay, I understand.”

As always, I was put into a deep sedation state with a propofol injection, and a nurse with a portable ambu bag was waiting at my side.

I looked at the patient.

“Then, let’s begin.”

The patient in deep sedation was not in a state to respond. He muttered something, but it was not understandable.

“Well, let’s go into surgery.”

I took the knife and made an incision about a hand’s length across the patient’s abdomen. I inserted the Richardson device and opened the incision wide–

“Evil!”

The patient screamed, but otherwise showed no reaction. This time, the anesthesia seemed to be working well.

I checked my gloves again, then put my fingers into the incision to grasp the colon with my hand. Amy held her breath.

“Oh, won’t it hurt… … ?”

This patient probably didn’t. The anesthesia worked well. Since it’s not general anesthesia but deep sedation, the results vary from person to person.

I grabbed the patient’s ileum and checked the appendix attached underneath. It hadn’t burst yet, but it was definitely larger than normal. Still, it seemed to be appendicitis.

I pulled the appendix out of my stomach and cleaned it out with saline solution. Amy looked at me and tilted her head.

“But, can I cut this out?”

“Huh?”

“You might need that.”

Well, the appendix probably has some function, but I don’t think it causes any problems if it’s not there. It’s much better to just cut it out.

“Because it’s already broken.”

“Aha.”

“Cut it out.”

Amy just cut the appendix out with surgical scissors. I took the sutures and sewed up the place where the appendix was cut out. It didn’t take long.

The place where the appendix fell out was about the size of a fingernail. I poured water to check if the intestine was properly sewn up, and then put it back down.

“It’s over, right?”

“Okay. Now I just need to sew up the skin.”

“But how do I organize this?”

“Just put it back in.”

Since I just pulled it out when I took it out, I just shoved it back in when I put it back in. There wasn’t really any other way. Of course, I had to watch it for a few days to make sure it didn’t get twisted.

The intestines are like long hoses, so there is no way to make them find their place. The main solution is to put them in and let them move on their own in the stomach.

I put the patient’s colon back into the body. Fortunately, I still had the appendix removed.

“Just sew it up, now.”

“Yes.”

Amy nodded. I sewed the patient back up and placed a towel over it.

****

The surgery was completed successfully. The patient was still in a deep sedation state, and we waited for a while until the sedation wore off.

“What are you waiting for?”

“Wait until the patient’s anesthesia wears off. The patient must wake up before you go.”

“Aha.”

“Yeah. You might not be able to wake up from a deep sedation. You might not be able to breathe properly.”

Amy looked at the appendix lying next to the operating table. It was a small, finger-sized clump of blood.

“It’s funny how a patient’s life is at stake because of something so small.”

“It’s a serious problem. If appendicitis bursts, bacteria and feces can spread throughout the stomach, causing a much bigger problem. Then it’s a matter of life and death.”

The patient was tossing and turning on the operating table. We looked over to see if the patient was awake.

“Thank you… … .”