Surgery with an "Appy" Ending

In which a Physician faces his own diagnostic failure when it counts the most

So God created mankind in his own image,
    in the image of God he created them;
    male and female he created them.

Genesis 1:27 New International Version

Years ago, when I was a freshman at Stanford, I acted in a few college plays. One of my favorite roles was E.K. Hornbeck, the cynical wise-cracking reporter in Jerome Lawrence and Robert E. Lee’s drama Inherit the Wind, about the Scopes “Monkey” trial of 1925. In this landmark case, John Scopes, a schoolteacher was put on trial for teaching Darwinian Evolution in a Tennessee high school, spurring a national conversation on the role of religion versus science in public education.

In the very last scene of the play in the narrowing beam of a spotlight, the Clarence Darrow character, Henry Drummond, picks up a copy of The Origin of the Species by Darwin in one hand and the Holy Bible in the other. Like a human balance scale, he hefts aloft each book, arms outstretched, and compares them briefly. He then dramatically slaps them together before dropping them both side by side in his briefcase – the spotlight fades to black. It is a very satisfying theatrical moment, but what is it actually trying to say?

With all due respect to the Bible, and not to be blasphemous, in my mind there is no comparison. If man was created in the exact image of God, so many things need to be explained away. For example, why the appendix? As a physician who spends an inordinate amount of time at all hours of the day and night anesthetizing patients for appendectomies, I have strong opinions about creationism versus evolution by natural selection. If I had to choose just one anatomical example in favor of Mr. Darwin, it would most certainly be the human appendix. Of all the ill-tempered, crazy things that the God of Abraham is credited for having intentionally done in Genesis 1:27, placing this useless and trouble-making stump of flesh at the beginning of our colon has to be near the top of the list. 

In our ancient pre-hominid incarnation as small ground dwelling mammals, the appendix may have played a more useful role, as it does in modern-day rabbits, rodents and other such buck-toothed chewing machines. There are several theories about what the appendix actually does. One theory posits that the appendix is a reservoir of beneficial bacteria, allowing mammals to ingest all variety of fibrous and impossible to digest foods. More recent research has discovered that the appendix contains a large collection of specialized lymphoid tissue, perhaps meditating intestinal immunity against pathogens. Despite this potentially rehabilitating bit of information, the relentless march of genetic progress via natural selection, random as it is, has largely relegated the human appendix, along with other vestigial structures such as the coccyx, the erector pilae muscles, and the plica luminaris to the trash heap of human appurtenances. Most people do quite well without it. 

It would be nice if the appendix just minded its own business, and quietly did whatever lymphatic thing it is doing and didn’t trouble us, or just continued to simply fade away into non-existence. But like an unsolicited sales call, or worse a Nigerian Prince phone scam, it occasionally and most inconveniently interrupts an otherwise pleasant trouble-free life by making its presence uncomfortably and sometimes dangerously known.

Appendicitis is a medical condition in which the appendix becomes infected and inflamed. Many people will develop appendicitis at one point or another in their lifetime. About 250,000 cases of appendicitis occur annually in the United States, and the lifetime risk of an appendectomy is estimated at 12% for males and 23% for females. It typically affects those under thirty, however it may occur at any age. 

Historically, the diagnosis of an inflamed and burst appendix was often a death sentence. Its rupture causes exposure of the contents of the bowel to the unprotected inside of the abdomen resulting in a condition known as peritonitis. This can lead to overwhelming sepsis, a critical life-threatening situation due to a breakdown of the protective lining of the intestine and gut bacteria entering the bloodstream. Prior to the invention of powerful antibiotics, sepsis was almost always fatal. Even with the wide variety of medications available today, including antibiotics, blood pressure supporting medications and ICU care, sepsis is still a leading cause of death in hospitalized patients. Fortunately, most cases of appendicitis are caught well before the appendix ruptures. With timely diagnosis and treatment, appendicitis is an easily treated medical problem – usually surgically.

The first recorded appendectomy was performed in 1736 by French surgeon, Claudius Aymand, who operated on an awake eleven-year-old for an appendix perforated by a swallowed straight pin. In 1804, the only person to die on the entire Lewis and Clark expedition was Sergeant Charles Floyd, due to an attack of suspected appendicitis.  At this time surgical anesthesia did not exist save for a shot of whiskey and a stick to bite on, nor did reliable intra-abdominal surgery, and there were certainly no antibiotics to be had at any price. It wasn’t until the latter part of the 19th century with the advent of general anesthesia and more refined surgical technique that it was possible to treat and cure appendicitis.

In my family, both my wife and my daughter have had appendicitis followed by emergency surgery. Dana had hers in the first trimester of her third and last pregnancy with our youngest and only daughter Kate. She in turn, had her bout of appendicitis at the tender age of four.

Dana’s appendicitis went something like this - She woke up in the middle of the night with nausea and a vague pain around the area of her bellybutton, and she jostled me awake to tell me about it. Given that she was pregnant, I wasn’t too concerned, as it is pretty normal to have a variety of abdominal complaints in the first trimester. I do remember being tired and cranky, however. “It’s just gas, go to sleep!” I grumpily said, rolled over and fell asleep. But Dana could not sleep. Despite sitting in a warm bath for the rest of the night, she felt worse in the morning. She vomited once and her pain had now moved to the right lower side of her abdomen. She did say she felt a little better after throwing up. This re-assured me despite the fact that the pain of appendicitis sometimes improves a bit before the condition gets much worse. Deep down I knew this, which brings me to the three “D”s of diagnosis

As is the case in many doctor’s families, these three “D’s” are critical in identifying any domestic medical problems that may arise. The first “D” is “downplaying” of the complaint. “Are you sure you’re really sick? Cause a lot of my patients are, and you don’t seem that sick to me...” This is a common phrase heard in mine and many other physician houses, and I am sure my family is definitely sick of hearing it. The second “D” is for denial. While for a brief second, I did consider that Dana’s constellation of symptoms might be appendicitis, I was far more worried about an ectopic pregnancy as that was entirely possible given her gestational age of ten weeks, a common time for such a problem. The third and final “D” is for “Dummy”, which is what I called myself when Dana was actually diagnosed with a nearly ruptured appendix several hours later when I was long gone to the hospital and working on my own patients.

Rather than trusting my medical instincts and relying instead far too heavily on my personality of always looking at the bright side of things, I did in fact leave my pregnant, sick wife at home with two small boys to take care of. It was not my proudest moment as a doctor, a father and most certainly a husband.  Fortunately, we have an amazing friend, Gina. We call her Saint Gina. She is a nurse and a super-mom, and as practical and able as they come. Soon after I had left for work, Dana called her to look after our boys because she was feeling too sick to get up. As soon as she arrived, Gina took one look at Dana and said, “You are going right to the hospital!”

In retrospect, it is good advice for physicians to leave the diagnosis and treatment of family members to others far more objective, and thus more competent. Once in the emergency room at the hospital, a surgical consult and an ultrasound of Dana’s abdomen revealed both a healthy intrauterine pregnancy, and a grossly swollen appendix ready to burst. In many cases a CT scan is also indicated, but this was held due to the fact that she was pregnant. 

Most appendectomies are done using laparoscopic surgery under general endotracheal anesthesia. Dana underwent an uneventful open appendectomy under spinal anesthesia in order to minimize both exposure to systemic anesthetic agents and to perform the surgery with as little disruption as possible to our developing fetus that eventually became our lovely daughter Kate. Dana chatted comfortably throughout the surgery with the anesthesiologist, one of my partners at UCSF, and she recovered perfectly. Six months later Kate was born, a healthy and beautiful baby girl. As luck would have it, young Kate would soon follow in her mother’s footsteps.

Early one evening when she was four years old, we decided to see “Harry Potter and the Chamber of Secrets” at our local theatre. She had been feeling a little poorly for most of that day and was a touch irritable. For Kate, irritable meant that she smiled only most of the time rather than always, so I thought a movie would cheer her up, and off we went.  She sat through the movie about young wizards and witches “spellbound” with the film; but I do remember noticing that her hand seemed a little warm to the touch, and she wiggled around in her seat every now and then like she was trying to find a more comfortable position. I also saw her grimace and stiffen a few times when she did move. What really got my attention however, was that she turned down an offer of candy and popcorn, so I knew something was really wrong. As we walked up the aisle at the end of the movie, she walked a little stiff-legged and was unusually quiet. By the time we got home, I could tell she felt sick. 

I laid her down on the couch in the family room and proceeded to play surgeon. “Does your tummy hurt?” I asked. She nodded. “First it hurt all over and now it hurts here.” She pointed at the spot in the lower right corner of her abdomen called “McBurney’s point” named after the surgeon who initially described the signs of appendicitis. Textbook answer. “Does it hurt more when I press, or when I let go?”  I gently pushed then released the spot to which she pointed. She winced as I let go. This sign indicates an inflamed appendix and a resultant sensitive peritoneum, the lining of the abdominal cavity. With a sinking feeling I knew we were going to the hospital. I could fool myself once, but not twice. 

It was now late in the evening, and the emergency waiting room at our local hospital was totally empty. Literally, crickets. Nevertheless, we sat there on the hard plastic chairs under the harsh glare of the fluorescent lights for what seemed to be an eternity. Finally, I couldn’t take it anymore and in my best doctor voice using every bit of medical jargon I could muster, approached the intake nurse and said, “Listen, my daughter is febrile, has peri-umbilical pain that has localized to the right lower quadrant, has rebound tenderness and is guarding. Could we please see the doctor on call - now?” The last word “now” was perhaps a little too emphatic and surgeon-like. She looked at me, her expression narrowed and with a voice dripping with condescension said, “My! We are using big medical words, aren’t we? Are we a nurse or something?” I resisted the urge to escalate and replied in as level a Clint Eastwood voice as possible, “No, we are a doctor or something. Should I use smaller non-medical words?”  I was being a total jerk but I didn’t care. This was my daughter after all.

Once in the ER, a quick urine test was negative for infection and a blood test revealed a high white blood cell count. Ultrasound again clinched the diagnosis.  Kate was a trooper through it all, bravely enduring a urethral straight catheter and a needle poke for a blood sample without so much as a whimper. Because our local hospital had neither pediatric surgeons nor dedicated pediatric anesthesiologists and I must admit, I felt more comfortable on my home turf, I called my friend, Mike Harrison, one of the best pediatric surgeons in the country, who came in from home and saw her immediately in the ER at UCSF as soon as we got there.

Surgery was quick and went well. Her appendix was nearly ruptured, but like Dana’s, we caught it in time. I remember thinking to myself during that agonizing wait after the anesthesiologist put her to sleep in my arms, and the hour or so later when I saw her in the recovery room, that I was so lucky to live in an area with so much choice and talent available, and that I had good insurance, had the ability to help manage her care and to be there for my daughter. Not everyone in this country is as fortunate and I knew that full well.

It is truly amazing that such a small, insignificant vestigial tube of flesh can cause so much trouble, but it most certainly does. Dana remembers her appendectomy as the time that our two boys, then age two and four were given free rein in the kitchen and on the computer. As she lay in bed suffering waiting for St. Gina to arrive, her doctor husband was taking care of his own patients instead of his ailing wife. Unsupervised, they went to town on the snack drawer and primed with sugar, they printed hundreds of pictures of Pajama Sam, Sly Fox, and Putt Putt the talking car, heroes of their favorite “Humongous Entertainment” games. 

Kate remembers enjoying the escapades of Harry Potter and especially Hermione Grainger a lot despite the pain in her stomach. She vividly remembers her late-night trip to the hospital where daddy worked and the popsicles after surgery. I remember being humbled and so thankful that we live in a time and place where we have immediate access to such wondrous medical technology, that we have amazing and supportive friends and colleagues and that an appendectomy is considered minor surgery. Though perhaps I should reconsider that final thought, as minor surgery is always something that happens to someone else.

Jeffrey Swisher, M.D.

Larkspur, CA