We have a young woman on the service now who came to my attending after getting nearly half a dozen surgeries in as many months at an outlying hospital. As far as we can make out from the scans that came with her, from her history, and from the op notes, all the surgeries, from beginning to end, were bases on poor diagnosis, were poorly planned, and poorly executed. She’s left with, among many other problems, an enterocutaneous fistula.

Classically, enterocutaneous fistulas are treated with bowel rest, which means not taking anything by mouth, and depending on total parenteral nutrition for weeks or months until the output dries up and the fistula closes spontaneously. Considering her underlying diseases, this is especially true for her. Her previous caregivers failed to follow this dogma, which is half the problem. (The other half stems from the original bad surgery.) So my attending came and had a very long – and for him, very sensitive – talk with her this morning, about how in six to eight months, we can have everything healed up and put together, and just about all the consequences of this reversed. But eight months is a long time for a person her age. And one or two or three months is a long time to not eat.

I thought she got the point. This afternoon the nurse came looking for me. “Your young lady is asking for something to drink. What are we supposed to tell her about when she can eat – a couple days, you think?” So I explained to the nurse, and then went to talk to the patient. It wasn’t as bad as a cancer talk, but nearly. I thought she’d understood what we were talking about, but clearly not. I went over it all again: what’s the problem in a fistula, how the only way to stop it is to stop the fluid from coming through, how surgery would be a really bad idea for her.¬†For patients who are just in for a few days waiting for their bowels to wake up after surgery, it’s easy to put your foot down and say no eating. I’ve already seen too many people miserable with ileuses when they ignore our instructions, or when we give in and feed them to soon. But for two months? There’s no way anyone can make her do that. She has to understand and decide to do it herself. She didn’t really talk to me, just sat there with tears trickling down her cheeks. Maybe tomorrow she’ll interact with us more.

She’s going to have several miserable months. Her life has been permanently altered by the ill-advised surgeries that were done on her. A surgeon made the mistake, and she’s paying for it. On second thought, I don’t care how long they make me wait to do anything. This is dangerous stuff.

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