Recurrent Small Bowel Obstruction and 24 Inches of Plastic Tubing

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24 inches of plastic tubing. Doesn't seem like much but it is one of the major pieces of technology in the non-surgical management of small bowel obstruction. The ER nurse knew my medical history so she knew I knew what was about to happen thus her explanation was relatively brief. In 2004, twelve years earlier, the descriptions and assurances were quite extensive as it was the first time I underwent the procedure. But on this afternoon, it was all done in short order. She coated the tubing with anesthetic gel and skillfully placed the nasal gastric tube.

24 hours earlier ........

April 22 Friday

I was at work having a mostly normal day. But inside, in my small intestines, things were not normal. Around 5PM, I began to experience abdominal pain. It was a familiar sensation. Over the years, sometimes the pain would go away after a few hours as the obstruction would resolve on its own in short order. On some occasions, the pain would remain at a low level for more than a few hours and then go away. On some occasions, the pain would escalate and the decision would be made to head to the emergency room. By midnight, the pain was present for seven hours and was increasing. We made the decision to head to the Ronald Reagan University Medical Center

April 23 Saturday

Emergency department (ED) waiting rooms are somber places. The patient waiting is in some kind of distress. The family member or friend bringing them in is concerned. 

The first point of contact with the ED is the triage nurse who asks some questions, gets medical history and takes vital signs. Some cases get moved right into the emergency room itself. Others are sent to the waiting area. Small bowel obstruction (SBO) in the early stages don't get moved to the front of the line so my wife and I waited quietly with about a dozen other people.

After an hour or so, I was called in. There are examination rooms with various equipment and there are designated areas in the hallway with a number on the wall where gurneys are parked. As would be typical for a big city ED there were many patients parked in the hallway and I was parked. 

ED's are like Las Vegas casinos in a couple of ways: there is a pretty constant beehive of activity and you have no sense of the passage of time unless you have a watch or someone to tell you what time it is. When you are in pain time seems to pass very slowly. I was eventually examined by a doctor. I can't remember how long it was I was parked in the hallway. But during the passing time, I could see and hear the stories of other patients and what pain has brought them to the ED. Some are in good humor despite the suffering and others wail in pain. I tip my hat to the medical professionals who live and work in this world!

I have been told UCLA tries very hard to encourage good doctor-patient communication experiences. The doctor came he asked me to describe (without any interruption) what I was experiencing. He then did a physical exam. He said given my medical history and current physical state, an SBO was quite likely and a CT scan was ordered. Pain (morphine) and anti-nausea medication was administered and I began the process of drinking the liquid contrast for the CT scan. 

Time passed and my drinking of the contrast liquid was slow. First, it tastes terrible and second, with a SBO (i.e. backed up plumbing in your gut), adding more fluid is very uncomfortable. The pain and nausea came back fiercely and I was given another dose of both meds. I eventually gulped down enough of the contrast liquid. However, the call to go to the CT didn't come. We asked about it and the nurse found out that one of the CT units had broken down so the backlog was causing the delay. 

Eventually, I was rolled to the CT suite and a set of images were taken with the contrast liquid. Then another set was taken using IV contrast that gives an indication of blood flow to the area being imaged. I was rolled back to my spot in the hallway.

The MDs (two this time) came back and said, yup, the CT showed a SBO so we are going to admit you into the hospital but the problem right now is that the hospital is completely full. However, a bed should open up in a few hours. 

At some point, I was moved into an examination room where the nasal gastric tube was installed and hooked up to the house vacuum system. By mid-afternoon, I was moved into Eighth Floor East Wing. The ED portion of the story was a least 14 hours.

The NG tube was gurgling and the IV was keeping my electrolytes in balance and giving me sugar for energy and I slept in short bits through the night.

April 24 Sunday

Psalm 27:1 The Lord is my light and my salvation - whom shall I fear? The Lord is the stronghold of my life - of whom shall I be afraid?

I was in 8-East so the window faced the morning dawn which roused me from my fitful slumber. I reached for the phone and snapped the picture you see above. 

The surgical team made their visit and said it was pretty much wait and see.

SBO is a fairly common reason people are hospitalized. If a patient comes into the ED and determined to have SBO and they have NEVER had abdominal surgery, the recommendation is surgery. Tumors of the small intestine can cause SBO and they would not be detected by imaging. However, if a patient has SBO and they have had prior surgery, non-surgical management is recommended since the case may resolve on its own. In the case of recurrent SBO due to prior surgery, the reality is that even the best of surgical techniques can leave scar tissue adhesions on the intestines which raises the risk of SBO. In my case, the surgery was in 2004 and this was my fifth recurrent SBO. 

Non-surgical management is not without risk. The main concerns are complications of the SBO. Strangulation of the bowel (blood flow being cut off) will lead to death of intestinal tissue and requires immediate surgical intervention. The other concern is perforation of the bowel that also demands immediate surgical intervention. Either can be fatal if surgical intervention is delayed. Thus, monitoring of the patient by direct observation, blood work up, and vital signs help the doctors know if things are going in a bad direction. 

But if the patient appears stable, it is watch and wait and hope the SBO resolves on its own. One clue is the how much material is being collected via the NG tube. When the SBO resolves, fluid once again begins moving forward in the intestinal tract and less material is extracted by the NG tube suction.

April 25 Monday 

Psalm 142:5 I cry to you, Lord; I say, “You are my refuge, my portion in the land of the living.”

With an NG tube placed and being in hospital (even if without an NG tube) is not conducive to high quality sleep and there is diminished quantity of sleep. Besides reduced sleep, physical weakness due to one's condition, and the uncertainty takes its toll on even the most positive of personalities. For me, I took to reading the Psalms on the Bible on my iPhone. I jotted down some phrases on the iPhone notepad that resonated with me. I've put some of them underneath the photos I took.

Check out this wonderful video of a conversation between U2 front man Bono and Bible scholar Eugene Peterson about the Psalms.

In the afternoon, the surgical team dropped by to check in on me. Based on the NG tube output and the x-ray they took in the morning, they decided to turn off the NG tube suction and installed a bag to collect fluid by gravity. The plan was to check back the next morning to see how much fluid would be collected.

April 26 Tuesday

Psalm 18:2 The Lord is my rock, my fortress and my deliverer; my God is my rock, in whom I take refuge, my shield and the horn of my salvation, my stronghold.

The surgical team came in and took a look at the NG tube collection bag and noted the volume and color. The volume was modest and the color consistent with gastric fluid. They decided it was time to take the NG tube out! The next test would be to have some liquid diet food for lunch and monitor my reactions.

Although I was already walking around (if at all possible patients are encouraged to get out of bed) the previous days, it is a bit easier with no NG tube. I did many laps around 8-East and ventured out to other parts of the 8th floor. I noticed the art work and below are pictures of some of my favorites.

Just love the humor of a picture of people looking at a picture!

Modern art can be hit or miss. At least this was kind of pretty and interesting!

Of course, you got to get an obligatory picture of a work by a famous artist like Worhol!

Hospitals and healing go together. In addition to the medical procedures and drugs, the other part of the equation is helping the patient's emotional state. I suppose that is part of the art collection to make the place seem more alive than just sterile walls. As I took my walks around the corridors, I came across many other patients doing the same thing. Some had an IV pole like myself. Others had many other things attached to them. But we all tried to give a smile to each other as we walked the hallways. I'm told also that there are more and larger windows in newer hospital design to bring more light in and allow the patients to see the outside world. In the rooms are couches and recliner chairs so that visitors can if they wish stay the night.

Visiting a patient in the hospital is not an easy thing to do for most people. It is a reminder of our mortality which is something most of us struggle with. Also, unless you have a special gift, knowing what to say or not to say is an issue. As someone laying in the hospital bed, I can only say that company is welcome. However, conversation readiness is highly variable from a patient perspective. Sometimes I felt filled with words that longed for someone to hear. But at other times, the medications or the lack of sleep or the aches and pains, the words were few and conversation was an energy drain and the silent company was needed and welcome. Thus, take your cues from the patient you are visiting.

Psalm 63:6 On my bed I remember you; I think of you through the watches of the night.

April 27 Wednesday

Psalm 19:1 The heavens declare the glory of God; the skies proclaim the work of his hands.

Good morning! Lunch and dinner (liquid meals) were tolerated from the day before. This morning was pureed food. By late morning, the word was given ... they were cutting me loose! The paperwork worked its way through the system and finally by early afternoon, my last tie to medical procedures was cut with the removal of the IV needle in my left forearm. Below is the IV pole on which hung the bags that fed me a saline solution with dextrose sugar and potassium for five days. The rectangular shaped boxes are the IV pumps. In my case, only one of them was active. I suppose some other patients might have multiple bags of things to be infused as there were three IV pumps on this pole.

There is no place like home!

Thanks to the doctors and nurses and staff of RRUMC. Thanks to friends and family who visited. And a huge thank you to Mrs. Rambler for love and support through this episode of "in sickness and in health" of our married life.

Previous SBO hospitalizations:

Disclaimer: The material above is a description of my health experience. Though I have attempted to be accurate I am not a medical professional. If you are in need of actual medical advice, please contact your physician.