“It’s bizarre to be given an award for being empathetic and kind,

which is what we all should be.”

Nazanin Boniadi

Actress and activist for human rights, former spokesperson for Amnesty International

We had just switched services, so now I was taking care of the Blue Team, with Kenna as my senior and Marcos as my chief.  Grant was the fifth year, but I didn’t see much of him.  He rounded in the intensive care unit and avoided the floor at all costs.  Jack had prepared me as best he could for the Blue Team attendings. 

     “Moezzi is only happy if he is pissed off about something.  He doesn’t know how to deal with happy or pleasant situations, so he always makes things unpleasant.  I think it all has to stem from some horrible mental trauma he suffered as a child.  He probably got made fun of all through high school because he is such a shrimp. But he never holds back, you always know where you stand with him.  He will lose his shit, scream and yell at you for a half hour, then he is done.  He doesn’t hold a grudge; he gets over things.”

     “Nayhan, his partner, is the opposite.  He is always calm and nice and pleasant, then will stab you in the back when you least expect it.  You never know what he thinks of you.  He’s technically really, really good, though.  He is the slickest one in the OR.”

     “Kaczanek is labile, unpredictable, and possibly truly insane.  I don’t know what else to say.  He expects you to know every detail about anything that ever happened to any of his patients.  He likes for you to spend like two hours per patient with him, which just kills you, you can’t get anything done, then everyone gets pissed at you.  But he’s the boss, you can’t just walk away from him.  You’ll just have to experience it for yourself. “  He gave me some pointers about the others, and I gave him the rundown on my service. 

     My first experience operating with Moezzi lived up to all my expectations.  Dr. Moezzi was on call for the house, and a very large fifty-four year old man had been admitted with abdominal pain, nausea, and fever.  Being on call for the house meant taking all the uninsured patients or the patients who had no referring doctor.  These, of course, were then called “house patients”.  House was the inpatient equivalent of Clinic.  Many of the house patients eventually became Clinic patients.  The attendings rotated the duty of covering the house, just like they rotated covering Clinic.  When a house patient came in, it was generally assumed they would not be a source of any reimbursement.  Most attendings just accepted this without much thought, as this had always been a part of what physicians do.  The medical profession has always been expected to provide its services to those who cannot pay.  No decent doctor is going to stand by and watch someone die from a perforated ulcer in the ER because they can’t afford the surgery.  But there were some physicians that groaned and bitched as if each house patient they admitted was going to push them into bankruptcy.  Dr. Moezzi was one of these and was on call for House. 

     Mr. Dugan had come into the ER with right lower quadrant pain for two days, a low grade fever, and an elevated white blood cell count.  He was unemployed and uninsured, so Moezzi would be his attending.  The patient’s last known weight was five hundred and forty pounds two years ago, and he thought he had gained a little since then.  On exam, we couldn’t really get a sense of where his pain was the worst.  His abdomen rolled over his thighs and extended down to his knees.  It spilled out over the edge of the bed on both sides.  Palpating his right lower quadrant seemed to cause pain, but the area was so massive I could not say it was over the area of the appendix.  The weight limit on the CT scanner was four hundred and fifty pounds, and he was too wide to actually fit into the scanner.  During medical school, we had on occasion sent people over to the city zoo, who had a huge scanner that could accommodate animals as large as rhinos, several thousand pounds.  But there was no zoo close to us here.

     With no way to reliably image him, Moezzi said to just admit him to keep an eye on him.  If it was an appendicitis, it would get worse.  No one wanted to operate on him, as we knew it would be extremely challenging, and potentially dangerous for him to undergo anesthesia and surgery.  He was guaranteed to have wound complications, respiratory problems, and a difficult recovery.  He had all the co-morbid conditions that go along with obesity and make wound healing more difficult – diabetes, high blood pressure, lung disease.  And he smoked and drank too much.  We were all hoping he would just get better and go home. 

     The next morning, he had a fever to one hundred and two degrees, his white blood cell count was higher, and he had more severe pain in his right lower abdomen.  Unfortunately, this was very consistent with acute appendicitis.  We made the decision to take him to the operating room for an appendectomy.  This is typically a forty-five minute case, and an intern scrubs with an attending.  I was really hoping my seniors would see that this was not going to be a simple appendectomy, and volunteer to do the case.  But as soon as Moezzi agreed the patient needed an operation, my name was slapped up there on the schedule.

     Just getting him to the OR was a huge production.  We had the mechanical lift-assist, which was a big, crane-like device.   A canvas hammock was placed under the patient by rolling him partly to one side, advancing the edge of the canvas under him, then rolling him the other way until it was worked underneath him.  The lift-assist was maneuvered over the patient and the hammock was attached to the frame with chains.  The crane elevated the patient, and with about six people surrounding him, we were able to get him onto a special reinforced gurney.  Once in the OR, we used the same type of device to slide him onto the OR table.  We had to put two OR tables together to accommodate his weight and girth. 

     The anesthesiologist was not happy with the IV, which was a small IV in his hand.  We could not find any visible veins in his arms, but he did have a reasonable external jugular vein.  The anesthesiologist got a nice large IV in there and administered the anesthesia.  Once asleep, we uncovered the abdomen and began the prep.  Two medical students and I retracted the large, flabby abdomen up to reveal the groin area and upper thighs.  The skin was moist and red, with the typical cheesy fungal infection found in the deep recesses of human skin folds that never see the light of day or a good scrubbing.  We needed to get this area adequately cleaned up or it could seed a wound infection at our surgical incision.  The nurse mopped up all the particulate stuff she could as we struggled to hold up the abdominal pannus.  She prepped the skin with the disinfectant solution, and we gratefully let down the generous apron of flesh.  She prepped the rest of the abdominal wall, and we scrubbed.  The OR was usually the place I most wanted to be.  It was like an oasis.  I could temporarily forget all my other obligations; they would have to wait until the case was finished.  It was my opportunity to focus on one thing, protected from all the other distractions.  When you are the medical student holding a retractor in a case, three hours seems like ten.  When you are actually involved in the surgery, three hours seems like one.  The fact that we could open someone up, rearrange and remove things, and leave them better off was always amazing.  But this is one case I was not looking forward to.

     Moezzi had just started doing appendectomies laparoscopically, so he wasn’t that great at the technique under normal circumstances.  Laparoscopic gallbladder surgery had just become standard, but laparoscopic appendectomies, or lap appy’s, were still rather new.  If we could get this appendix out laparoscopically, or look around with the laparoscope and see a normal appendix, we could save him a big incision and lower his chances of post-operative wound complications.  In a patient this size, we had a very high chance that his incision would not heal.  Moezzi got up on two steps on his side of the patient, and the student and I climbed up on our steps.  The tables were as low as they could go, but the immense abdomen was like a mountain before us.  We had the extra long instrument set, and we proceeded.

     Moezzi made a small incision at the umbilicus and starting dissecting down through the fat trying to reach the fascia, the tough outer layer of the muscular abdominal wall.  We needed to grab the fascia, pull it up and incise it, then go through a thin layer of tissue, then through the membranous lining of the abdominal cavity to get inside the abdomen and find the appendix.   Moezzi readjusted the lights, and I tried to retract as best I could, but he was staring into a deep hole with a small opening, with no sign of the fascia.  He made the incision bigger, to give us more room to see to the bottom of the hole and continued digging deeper into the tissue.  He grabbed at some flimsy layer about six inches deep, thinking maybe he had fascia.  It just shredded – more subcutaneous fat.  He made the incision even bigger to get more visualization as we probed deeper and deeper.  Then he started complaining.

“The whole advantage of laparoscopic surgery is to have small incisions – this guy is so fat he is going to end up with a six inch incision just so we can find his fascia.  Unbelievable, unbelievable.  How do you let yourself get this way?” he groaned.

     We finally located the right layer, got some sutures into it and pulled it up.  Moezzi sliced it open with the scalpel, and nothing but fat protruded up through.  He tried to get his finger in to sweep through the thin layer of fat into the abdominal cavity, but it was too deep.  We struggled for a while and finally got a long clamp through the layer and into the abdominal cavity.  A moderate amount of yellow infected fluid welled up from inside.

“Well, shit, he’s got something going on,” Moezzi sighed.

     We placed the port and tried to inflate the abdomen.  For laparoscopic surgery, space is created in the abdomen by inflating it with carbon dioxide, like a big balloon.  Then we have room to see things and move our instruments.  We turned the gas up to high flow, but the abdomen would not fill with gas.  The weight of the abdominal wall was too much for the gas to move.  We turned the gas flow up more and more, hoping more pressure would lift the abdominal wall up.

“I am having trouble ventilating him, his airway pressures are going sky high,” anesthesia warned us.  The gas pressure was not enough to lift the massive abdominal wall, but was high enough to push his diaphragm up and compress his lungs.  We went down on the pressure.

“Oh, that’s much better.  We are back to normal up here,” the anesthesiologist said.

     We were not able to get the abdomen insufflated, which again sent Moezzi into a tirade about morbid obesity.  We decided to extend our already large incision the rest of the way down his midline, and opened the fascia widely to expose the abdomen.  We suctioned out about two hundred milliliters of pus.  We initially did not see any bowel.  A thin apron of fatty tissue called the omentum typically drapes over the intestine, to protect it.  It usually easily slides out of the way.  His omentum was almost two inches thick and was stuck to the right abdominal wall.  I placed an extra long retractor and pulled hard to try and expose the area of the appendix.  We still couldn’t see the abdominal cavity clearly, because the immensely thick walls of the abdomen created such a deep hole.  I felt like I was standing at the edge of a deep, dark well, trying to identify what lay at the bottom. 

“Why don’t you tie a rope to yourself and we’ll lower you in there,” the scrub suggested to Moezzi. 

     He was such an ass in the OR, I think the staff got a kick out of watching him struggle.  He ignored her.  He extended the incision more to try to get wider exposure and a better view, and we tried to place a self-retaining retractor.  Even the extra long retracting blades couldn’t span the whole depth, so I used a hand- held retractor as well.  The student had one and was also pulling for all he was worth.  Beads of sweat formed on his head.  I hoped he didn’t pass out or anything, because I could not keep this colossal abdominal wall out of Moezzi’s way by myself.   Moezzi was grumbling obscenities under his breath, cursing fat Americans. 

“This is not surgery.  This is not human surgery.  I can’t even begin to see anything except fat, how am I supposed to get a god damn thing done?  How do you let yourself get this way?  How is it possible?”

     He pulled the inflamed omentum loose from the right lower quadrant.  It had been stuck to the gangrenous appendix.  We could just make out the tip of the appendix, which was green and slimy.  More pus welled up as Moezzi stuck his arm down into the abdomen and tried to free up the appendix and get it into view.  My arms were aching from pulling so hard on the retractor.

“I can’t see shit in here.  Pull on that harder, I have to see down there,” he instructed.  We were almost two hours into the case and had accomplished nothing.  The colon had large fatty appendages that were hanging down, obscuring the base of the appendix.  Moezzi started grabbing these and stapling across them, removing them to try and clear the field of some excess tissue.  Then he started grumbling about not even getting paid for all this work, it was ridiculous, unfair, an unjust persecution of him personally. 

“You think this guy spent the last forty years eating like a hog to get hugely fat then caused his appendix to rupture just to ruin your day?” the scrub inquired. 

“This is not the time for jokes-we have a serious problem here.  We cannot complete this operation, this is no joking matter.  Even if I get this appendix out, he’s going to die because he is so fat.  Nothing will heal.  Look at this huge incision we had to make because he is so fat.  This is ridiculous, I have never, ever had to make an incision half this big for a damn appendix,” he snapped. 

     He was frustrated, about to go over the edge, and the staff in the room were enjoying the opportunity to push him a little.  They had all been the object of his unmerited condemnation at one time or another, so took some pleasure in watching him struggle.  We worked laboriously  for almost another hour to identify the base of the appendix and dig the midportion out from behind the cecum.  It was long and folded nearly in half, tracking down behind the cecum and coming back up.  It was gangrenous, with a big perforation at the deepest point.  It actually came out in chunks, rather than one nice specimen.  We spent a good amount of time irrigating and cleaning up the abdomen, and an equally long amount of time closing the deep fascial incision.  He was high risk for having the wound break down, which would be disastrous for him.  We did not want to close his skin, as this would definitely result in a wound infection.  Moezzi instructed me to pack the wound, and he left, nearly four hours after we had started this appendectomy.  He had done nothing but complain about fat for the last two hours of the case.  I felt like I had just finished a four-hour aerobics class.  My arms hurt, my back hurt, my legs hurt.  My neck hurt from straining to look into the belly to try to help Dr. Moezzi.  The poor medical student was slumped on a chair in the corner, trying to restore some blood flow to his cramped forearms and hands.  I got the dressings put on and started the ordeal of moving him back on to a gurney for transport.  They were afraid to extubate him, so he would be going to the ICU on the ventilator.  I looked at him, with his huge open wound, on the ventilator, unconscious, and on his way to the ICU, all from a simple appendicitis.  

     He spent the next day on the ventilator, unable to breathe adequately on his own.  By the second day, he was off the ventilator and the endotracheal tube was out.  He transferred out to the floor, back into my daily routine.  He liked to talk, and I learned he had a long history of drug abuse but had recently started to straighten himself up.  The only visitor he ever got was a counselor from the crisis center he had been going to for the last month.  He had a father not far away, but they had not talked for over six years.  The guy didn’t blame his father, he had stolen some things from him to pay for drugs.  But he was off drugs now, was looking into a job assistance program to get some sort of computer based job and wanted to try to start managing his weight.  He knew it was killing him. 

     He had actually been doing okay until the fifth day after surgery.  He got a fever and had more pain in his abdomen.  His white blood cell count started going up again.  We were worried about an abscess in his pelvis but had no way to scan him or x-ray him because he was too big.  We tried an ultrasound, but the picture was not clear enough to help us.  There was too much tissue between the ultrasound probe on the skin and the inner abdomen.  The only way to see would be a trip back to the operating room, and no one wanted to end up back there.  Unfortunately, the next day our hand was forced.

     I always went to his room before morning rounds and did the dressing change, because it took about twenty minutes, and we didn’t have twenty minutes to spend on a patient during morning rounds.  I had removed the gauze dressing and started taking the packing out of the wound but knew something was wrong before I even got to the bottom.  There was enough thin fluid seeping up from the depths of the huge wound to make the gauze packing float, and as I pulled up the bottom layer, I saw small intestine.  He coughed, and about three more feet of intestine came up out of the wound.  The medical students’ eyes got big, and I shoved the intestine back in and placed a big moist towel over the wound.  I had the students put pressure over the dressing and instructed them not to move.  The deep layer of his wound had broken down and opened.  I hurried out to find Kenna. 

“Are you sure it was bowel?  It may have just been fascia.  Sometimes that can look like bowel wall,” she questioned me, thinking this was probably just an intern overreacting.

     She took a look herself, then quickly explained to Mr. Dugan that we would be going back to the operating room to fix this problem.  She added him on to the OR schedule and called Dr. Moezzi, who was very, very unhappy about this development.  I stayed with Mr. Dugan to get the consent form signed and to take care of all the little details.

“You guys have all been saying how dangerous it would be for me to have another surgery, that I might not get off the ventilator again,” he said nervously.  “Is there anything else we can do?”

“No,” I answered.  “There’s only one way to fix this.  You can’t live with your bowel exposed and the abdominal wall open.  We have to go back to the OR and fix it.”  I tried to reassure him that things would be fine, he may have a rough course, but things would be fine. 

“I have a terrible feeling I’m about to pay for everything I’ve done.  All the bad choices, all the people in my life I hurt and let down.  I don’t think I’m ever going to leave this hospital,” he said, looking at me as he touched my arm. He was frightened and uncertain. “Let Karen Maynard know I was really going to turn my life around.  I was really going to do it this time.  She’s that counselor.  When no one else gave a shit about me, she really helped me.  Let her know that, if you see her again.”

     Again, I tried to reassure him things would go fine, and got the paperwork signed and in order, and the orders done.  Thankfully, Kenna would be handling the case. I could already imagine Moezzi launching into another endless rant about obesity and how the universe was against him.  The patient was morbidly obese, but after spending a few days talking with him, I saw him as more than that: a very frightened man afraid he might die.