You all know the setup by now: mysterious mass on left kidney, two urologists agreed said kidney would have to come out, scheduling problems, illness, delay, repeating the preoperative testing, and then into Brigham and Women's Hospital in Boston a week ago yesterday for the operation.

Pre-op was normal; I was scheduled for surgery at 11:20 Monday before last, with a requested arrival time of 9:20; I was a little early, the hospital was running a bit late. After running through the paperwork one last time and hanging around the desperately dreary (because trying really hard not to be) surgical admitting waiting room for a while, I was shown with my expedition party into the bowels of the hospital. The pre-op area at BWH looks like what emergency rooms used to look like when I was a kid, all rows on rows of identical curtained-off cubicles, and when a surgery day is in full swing it's a bit like the pits at a race track as well: dozens of little teams of similarly dressed individuals in similarly equipped little adjacent environments beavering away diligently at similar tasks.

This is where you trade your regular humanity for patiency, packing your normal self away in a plastic bag labeled PATIENT BELONGINGS with your street clothes and shoes - like them, you won't be needing him again until you leave, if then. You put on a gown and some socks, sit on a gurney, and wait for people to come stick needles in you, tell you what to do, and ultimately wheel you away to another, more intent and purposeful room, to do more intent and purposeful things to you.

In my case I had been slated for a laparoscopic nephrectomy, that is, a kidney removal in which the surgeons use tools and cameras inserted into the patient's gas-inflated abdomen through small incisions rather than making one great big one, applying a bunch of retractors, and whatnot. I'd been warned repeatedly, though, that the odds were good the team would have to conver to the old-fashioned open approach at some point. There are a lot of conditions that have to be ideal for major surgery to work laparoscopically, and I am not the sort of patient in whom those conditions are frequently ideal. Still, Dr. Kibel saw nothing to lose in starting off that way, apart from possibly a little time.

In pre-op, once converted fully into a patient, I met with the anesthesia team for the day (not the same ones as on the day we aborted). They were all youngish and cheerful, two men and a woman, and their leader explained that they had a particular need for my cooperation in these opening stages. You see, they would be using a breathing tube for my anesthesia in this operation. Owing to my avoirdupois and the position I had to be in for the procedure, they would have to do the intubation before putting me under.

They gave me the first shot of the unspecified Medicine To Relax You at this point - Versed, I would guess - and as the room went a bit funny one of the anesthesiologists said, "You'll be conscious, but you won't remember it after. Heck, you probably won't remember this conversation."

But I do, and I remember being intubated, too - by a junior anesthesiologist at the senior's instruction, which is one of the... well, I hesitate to call it a pitfall of having your procedure done at a teaching hospital, actually, since he did a good job. They use a fiber optic camera and a lot of something that's like a super-industrial Chloraseptic applied with a paint gun, along with a "bite on this" plastic positioning thing. It seemed like they had a difficult time with it, taking several attempts to get it in position, but I didn't get the sense that this was anything more than "well, tricky case, let's not be in a hurry." I remember, before they made the last attempt, thanking everybody for their help and getting a chorus of kindly you're-welcomes. Then the tube was in, I gave the anesthesiologist a thumbs-up, he turned a valve, and I was out. Bang. Just like that. No counting backwards, no swimmy video effect, just like someone shut off the lights.

I had been told before arriving in the OR that the procedure was expected to take two to three hours, involving no siginificant loss of fluids even in the relatively likely event that the team had to convert from laparoscopic to open protocol (at which point it would probably take more like four hours). My surgical team consisted, in addition to the three anesthesiologists and an unspecified number of nurses, of Dr. Adam Kibel - BWH Chief of Urology - and his assistant Dr. Stephen Eyre, a urology resident. I went under, I think, at around 12:30 PM.

I came to for the first time - just - to find myself in a completely unfamiliar room, strapped to the bed, still intubated, surrounded by people who all seemed to be talking at once and none of them to me. A nearby window made it plain than it was dark outside, and there was a clock on the wall that I could not read because my glasses were gone. It took a few moments for the people around me to notice I was awake, at which point one of them loudly expained that she was a nurse from Respiratory, it was around two o'clock Tuesday morning, and I was still intubated because "we're using the tubes to medicate you. We had to open you up. You're going to be OK. Just hang in there."

I got the distinct sense from all this that something was not quite right, but I wasn't what you would really call coherent just then. There was a heavy pall of lingering druggedness, and there was the huge distraction of being tied down and still intubated, which combination made it nearly impossible to communicate, and I found that more alarming than the implications of the young woman's shouted semi-explanation of what was going on.

Having a breathing tube in is a deeply weird and disturbing experience. It's providing all the gases you need and taking away the ones you don't, and so you're in no danger whatever of suffocating, but you aren't breathing, and there is wiring way back in the limbic brain that says there are no circumstances whatever under which that can possibly be acceptable. In retrospect I think they thought I was trying to either get fighty or pull the tubes (I could feel two with my tongue) out, which is why they had me strapped down, but what I was really trying to do - and this is preposterous as well, but at least peaceful - was point out the tubes, as I was momentarily convinced that the team must have forgotten they were still in me.

What followed, for the next four or five hours, reads in my memory a bit like that scene in RoboCop where they're building the title character and keep turning him on and off to adjust things ("I thought we agreed on total body prosthesis, now lose the arm"), except without the wild party. Though I relish the mental image of a flushed and triumphant Dr. Kibel leaning over me and snarling, "You are gonna be a bad motherfucker!"

Things eventually stabilized, they hauled the tubes out of me and unstrapped me from the bed, and then everyone left me to lie there and be quietly exhausted for a while. It took me several days to get the full story out of a variety of medical visitors, but here's the full story, paraphrased from a copy of the surgical report I obtained before my release.

Basically, divorced from most of the medical jargon and weird dictation artifacts ("Great care was taken to pad sufficiently in particular by placing egg crate under entire buddy"), what it says is that the laparoscopic operation was very difficult (as expected), but they were getting it done, until the time came to separate the kidney and its surrounding mass of fatty tissues (which is extracted in these operations en bloc for the pathologists to sort out at their leisure) from its connections to the circulatory system. Each kidney has one very sizeable artery and vein supporting it, and they enter the kidney at the same point, along with the ureter (the tube that takes urine to the bladder) and various nerves and whatnot. This nexus point is known as the renal hilum.

In laparoscopic nephrectomies, the usual procedure is to line up a device that crosses the entire hilum, severs everything in it, and staples the blood vessels all in one smooth action. In my case, they did this and the device severed the artery and vein perfectly... and then did not staple them.

At which point, basically, all hell broke loose.

The team tried to increase the pressure (because the gas pressure involved in laparoscopy helps contain blood loss as well as keeping the tent up, so to speak), finish the job and GTFO, but, as the report puts it, "it became very apparent very rapidly... this was not going to be possible." At this point they switched to an open procedure "emergently", which - as Dr. Eyre told me later - posed its own set of challenges, since they'd have to turn the pressurizing gas off but they wouldn't have the open incision made immediately - there are a lot of layers involved in reaching the abdominal cavity in a person my size. While the two surgeons worked on that, the anesthesia team found themselves confronted with the classic bleedout scenario of plunging blood pressure, spiking heart rate, and a generally tough day at the office - more or less in parallel with, and largely independent of, what the surgeons were up against. There is reference in the report to "fluid resuscitat" and "pressors".

Eventually the surgeons were able to get a big enough hole open that they could haul out the kidney and its attending impedimenta, which were whisked off to the lab to become the pathologists' problem. Then - and only then - could they tackle the renal artery and vein, apart from stuffing in a whole bunch of sponges and, I would assume, swearing a lot during the laparascopic-to-open conversion phase. The report shows that they called in not one but two other surgeons, one - another urologist with the outstanding named "Dr. Graeme Steele" - "to assist with attaining hemostasis" and a second specifically to track down the renal vein, which had apparently escaped in all the confusion. The fourth - Dr. Michael Belkin, no less a figure than the hospital's chief of vascular surgery, I've just discovered - had to go clear back to the vena cava to trace that bad boy down and get it tied off.

By then, well... here is a quote from the report that sums up the situation better than I ever could.

"ESTIMATED BLOOD LOSS:
6.7 L.

IV FLUIDS:
6 L of Ringer's lactate, 11 units of packed red blood cells and 8 units of FFP."

So. Bit of a near thing, what?

Yeah. The first thing Dr. Kibel said when he saw me later on Tuesday was, "You scared the hell outta me."

I spent four days in the BWH Intensive Care Unit (oddly, in the "burns & trauma" ICU, not the surgical one - I think that was simply an availability-at-the-time issue, since they weren't expecting me to go to Intensive Care at all), receiving constant infusions of more Ringer's, and on Wednesday they gave me a unit of blood, whilst all the while the lab nervously eyed my hematocrit levels. These recovered to a level they considered acceptable after that Day 3 transfusion. (Dr. Eyre said during one of his visits that he'd have liked to throw another unit in there just for good measure, but that modern-day blood transfusion regulations have strict parameters that I no longer quite met, so he couldn't.)

By late Thursday, the team considered me ready to move to a regular bed on the urology unit, but they couldn't find one, so I remained in ICU until late Saturday evening. Even then what they found me was not a bed up on the urology unit, but down the hall from Intensive Care in one of the general patient wards. I don't wish to seem I'm talking out of school here, but even once you correct for any unfair expectations that may have been set by my week in ICU, the nurses on the floor where I was subsequently sent seemed to be of a... somewhat lower caliber. Their response times to the call bell, their handling of (or lack of handling of) my wound dressings, and the way they dealt or didn't deal with my bathroom troubles (about which, mercifully, I'll say little here) on Sunday all led me to the conclusion that they just didn't have things entirely on the ball in 8A.

Anyway, that's neither here nor there at the moment and hopefully will remain that way. It represents the one shadow on what was otherwise a textbook illustration of exactly why I wanted this operation done by someone of Dr. Kibel's stature, in a place like BWH. Smaller hospitals may be good ones, but they simply don't have the depth. I mean, they called the chief of vascular surgery out of the bullpen at what must've normally been the end of his day to step in and quite possibly save my life toward the end of this adventure. I'm not sure that would, or even could, have happened for a regular consulting urologist at a hospital in Bangor, Maine.

I'm home now; a visiting nurse stopped in today, gave me some advice for dealing with the MaineCare bureaucracy, and didn't like the looks of my last round of BWH dressings (applied in 8A before I left), so that may be a developing side quest, but it's too soon to tell. Similarly, there's been no word from Pathology about what they found in the extracted tissues; that may take up to another week, and not until we have that report will Dr. Kibel and I know the full prognosis.

For right now I'm just trying to focus on being pleased that it didn't all end with a misfiring staple gun on a table at BWH last week. I'm very grateful to the whole surgical team, and the outstanding staff of 8C, the ICU floor I spent most of the week on, as well as everyone out there who's given me love and support during this adventure. It isn't over yet - may not be over by quite some way - but at least that part's done with.

I might still have several battles to fight, but I keep trying to focus on the fact that I've already won a huge one just by making it through last Monday. Six point seven liters. That's a lot. That's one and three-quarter gallons. You could probably paint my living room with that, if you didn't do the ceiling or floor.

--G.
-><-
Benjamin D. Hutchins, Co-Founder, Editor-in-Chief, & Forum Mod
Eyrie Productions, Unlimited http://www.eyrie-productions.com/
zgryphon at that email service Google has
Ceterum censeo Carthaginem esse delendam.

And, on average, the human body holds about 4 liters, give or take. So that's all of your blood, and then a good deal more of it all over again.

In any event, you survived, and that's the most important part. (I confess, I am interested in seeing how this particular life experience gets alluded to in your writing, after seeing how you worked MS in.)

I'm curious (since this is related to something I'm doing at work right now): have you encountered the word "albuminuria"? I'm sure it's something you will be hearing sooner or later in the Great Renal Adventure.

"Mathematics brought rigor to economics. Unfortunately, it also brought mortis."
- Kenneth Boulding

Versed is a wonderful thing. And I heartily agree about the staff on some floors being better than others in the same hospital. A few months back the doctors got so irritated with the care my dad was getting from the nursing staff, they actually had him moved from a general surgery floor to an ICU step-down floor, then argued with the insurance company about it for my mom.

Don't get impatient and overdo things, and feel better soon!

Jeanne

	Jeanne Hedge http://www.jhedge.com
"Believe me, if I have to go the rest of my life without companionship, knowing myself won't be a problem." -- Gabrielle of Potadeia

Holy crap.
I wouldn't want to be the guy that has to empty the Shop-Vac after that.
But seriously, thank whatever deit{y|ies} or force{s} for getting through that.

Polychrome

Yes, I know they don't actually use a Shop-Vac.

"ESTIMATED BLOOD LOSS:
6.7 L.

O.O Gryphon... are you secretly an anime character? God, that's a lot of blood.

I'm just glad to hear that you're recuperating, and I pray for a fast recovery.

-- ∇×V

Brian

> In my case, they did this and the device severed the artery and vein perfectly... and then did not staple them.

When you go in for your followup, ask for the information that the hospital submitted to the manufacture of the device. Per the FDA, they're required to report the event as it screwed up. I think as bad as it screwed up, they might even have to file with the FDA.... anyhow, reasoning is that you might be able to get someone else to pay the bills for a while if insurance doesn't cover it all (and since when does it?). If you want to go that route.

--
Andrew

Jesus. Well, uh, I'm kinda late seeing this but...I'm glad you didn't die while I was off getting kicked around by my classes. Sheesh. Did they change the filter while they had you up on the lift(The FRAM^® Extraguard^TM! 3x the blood filtration of our competitors' kidneys!)?

Welp, back to reading updates...
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