Episode 7: The Bowels Awaken (albeit rather slowly)

Day 8 - Tuesday September 13

The overnight MD for 8-West is usually just one person for the unit but since the team showed up it must have been the transition to the morning shift that happens around 5AM.

The MD in charge asked a few questions and the order was given: nasal gastric tube insertion. In a matter of minutes, the tube was placed and in a matter of minutes hundreds of milliliters of fluid was collected in the vacuum trap. This would be the eighth time I've had this medical device utilized for my medical care - the second time during this hospitalization.

Eight days earlier .....

Day 1 - Tuesday September 6

On this day, I was scheduled for Laparoscopic Lysis of Abdominal Adhesions (video) (text explanation) at 1pm.

Briefly, I had surgery for small bowel obstruction in 2004. As a result, I was at risk for recurrent small bowel obstruction (SBO) due to adhesions from scar tissue formation resulting from the surgery. Most adhesions don't cause problems but some do and in my case, recurrent SBO episodes took place in 2005, 2009 (spring), 2009 (fall), 2014, and 2016 (spring) all resolved by non-surgical management using the nasal gastric tube and supportive IV.

After the episode in 2014, the surgeon in charge of my care said the number of recurrences is getting to be unusual high and elective surgical intervention might eventually need to be considered. After the episode in 2016, the surgeon in charge of my care (different MD), made a more insistent recommendation that elective surgical intervention should be very seriously considered. As a result of that recommendation, I was scheduled for elective surgery on this fine fall southern California day.

I checked into the procedure treatment unit (PTU). I changed into the surgical gown - a neat little thing that can be hooked up into a warm air blower! The nurse placed the IV catheter into my left hand. A member of the surgical team gave me a quick rundown of what to expect. For this type of surgery two hours would be typical if nothing unusual is found inside. The plan was to use four laparoscopic sites. However, if things got complicated, they would resort to a laparotomy. Blood transfusion is not anticipated but my blood type was determined should it be necessary.

I was informed that the surgery in the surgical suite I was scheduled for was running overtime and that there is a 45 minute sterilization procedure for the room before it would be ready for my surgery. I would know the surgery would be soon when the anesthesiologist checked in with me.

At 2pm, the anesthesiologist came by and explained what will happen. He and one of the medical students on the team walked with me as the medical bed threaded its way to the surgical suite. He asked about my research work and I asked him about his. Once in the surgical suite, I was transferred onto to the surgical stage. The anesthesiologist hooked me up to an IV and he explained he was beginning the process of putting me under. I was beginning to fade out. He placed an oxygen mask over me. I think the last thing I said was, "God bless you all." He said, "God bless you too."

I woke up in the post-anesthesia care unit (PACU). I was told by the surgeon that my case turned out to be more complicated that expected. Instead of just a few adhesions localized to one area there were dense matted adhesions in two areas. However, the team decided a laparotomy was not needed though it took nearly four hours to release all the adhesions.

With the anesthesia worked out of my system, I was moved into the transitional recovery unit (TRU). The regular surgical unit patient rooms on the eighth floor were full so I would be cared for in the TRU that is meant for recovery of out-patient procedures during the day. However, in a pinch they can be converted to regular recovery if somewhat cramped space for in-patients.

Day 2 - Wednesday September 7

A little after midnight, I hit the call button and reported feeling nausea. I was given some anti-nausea medication. I think it was around 2:30AM when I hit the call button again as the feeling came back and was much stronger. This time the overnight MD came in and explained nasal gastric tube insertion was necessary since I was suffering from post-operative ileus as my bowels were asleep as they don't like to be handled and four hours of handling had just taken place.

Day 3 - Thursday September 8

By nightfall, room 8331 opened up in 8-West. The IV fluids kept me hydrated. The NG tube suction kept the nausea and abdominal pains at bay.

Day 4 - Friday September 9

In the afternoon, the amount of fluid collected by the NG tube decreased enough that they removed the NG tube.

Day 5 - Saturday September 10

I began on some liquid diet with the plan of a discharge on Sunday. I felt the liquid food was still feeling a bit "heavy" but it wasn't too bad.

Day 6 - Sunday September 11

I was advanced to some solid food but it was was still feeling a bit "heavy" and it felt worse that on Saturday. The MD examined by abdomen and canceled the discharge order. One thing MDs try to avoid is sending people home only to have them come back into the ER with post-surgery complications. They thought that the post-operative ileus might still be hanging on.

Day 7 - Monday September 12

I went back to the liquid diet. It was still feeling a bit "heavy" and it was beginning to feel painful in my belly. I was given toradol since opioid (morphine and morphine-derivative) meds often slow down the digestive tract.

Day 8 - Tuesday September 13

Sometime after midnight, I can't remember when, I felt very bloated. There was so much air trapped in my belly that I belched repeatedly and it seemed to go on forever but it was probably just a couple of hours. Eventually, I hit the call button to report my situation to the nursing staff. They suggested that I get up and walk and see if it would clear up. I was able to walk around for a handful of minutes but I was starting to feel very weak and unstable and the nurse could see that I was at risk of falling so she brought me back to the room and had me sit in the chair. It seemed like a long time but was probably less than an hour when things started to go seriously sideways.

The nausea was welling up fiercely but vomit attempts come up dry after multiple attempts. The abdominal pain was off the charts; easily a 9 or 10 on the 0-10 pain scale the staff asks their patients to report their pain experience. I found sitting in the chair was getting very uncomfortable so I lowered by myself to the floor and put my face in the bucket in the hope vomiting would bring relief. But relief did not come.

I realized this was not going well and I hit the call button but was too weak to explain the reason for my call. The nurse came in and it was clear I was in distress and she was soon joined by several others. They tag teamed carried me off the floor and put me into bed and after a few questions and my weak attempts to describe what I was going through, the nursing staff paged the medical staff.

UPDATE: Was revisiting this post 1 year later and thought I'd add a few thoughts about morphine type pain medications. Clearly, there are occasions where receiving morphine and morphine-derivatives is entirely appropriate medically. For my SBO condition, I have generally declined the morphine because they can "slow down" the intestinal tract. You may have seen TV ads for the condition called OIC, opioid induced constipation. For people who have chronic pain and take opiod type medications, they often have constipation. Thus, in most of my hospital stays, I opted out of the morphine but did take it on a few occasions. So indeed, there were occasions when the pain was just too much and I would get the shot and the pain would dial down and one even feels a little euphoria as a result. However, at least for me, I would feel a miserable "brain haze" and overall "icky feeling" as it wore off. 

The overnight MD for 8-West is usually just one person for the unit but since the team showed up it must have been the transition to the morning shift that happens around 5AM.

The MD in charge asked a few questions and the order was given: nasal gastric tube insertion. In a matter of minutes, the tube was placed and in a matter of minutes hundreds of milliliters of fluid was collected in the vacuum trap. This would be the eighth time I've had this medical device utilized for my medical care - the second time during this hospitalization.

The NG tube drew out liters of fluid through the day.

I found solace recalling the familiar Psalm written by David.

Psalm 23

The Lord is my shepherd, I shall not want
He makes me lie down in green pastures
He leads me beside quiet waters
He restores my soul
He guides me in the paths of righteousness For His name’s sake.
Even though I walk through the valley of the shadow of death
I fear no evil, for You are with me
Your rod and Your staff, they comfort me.
You prepare a table before me in the presence of my enemies
You have anointed my head with oil
My cup overflows
Surely goodness and lovingkindness will follow me all the days of my life
And I will dwell in the house of the Lord forever

Day 9 - Wednesday September 14

Somewhere around mid-morning, I was wheeled down to the x-ray unit where contrast was delivered through the NG tube. The plan was to take a series of x-rays to monitor the flow of the contrast through my GI tract to see what was going on inside. Suffice to say I threw up some of the contrast but enough was inside me for the study to go forward. I can't recall how long I was down at the x-ray facility and at what intervals the x-rays were taken. Eventually, I was wheeled back up to 8-West where the portable x-ray unit would take additional pictures at designated intervals. By 3pm the nausea and pain from the fluid build up was too great and the NG tube suction was restarted. Additional x-rays were shot in the afternoon and early evening.

UPDATE: Revisiting this blog post almost a year later, I should note in regards to morphine (see notes on day 10), I did take some on this occasion in the late afternoon. Though the pain wasn't as intense as it was on day 8, it had just been so many hours of discomfort that I took the shot. Would also like to discuss, anti-nausea medication. The feeling of nausea is miserable. We know that feeling from sea-sickness (for those who have that problem - I do!) - that "I need to throw up and need to throw up now feeling." Of course, a lot of times, we don't actually throw up and it just feels icky. Anyway, I find nausea medicine takes the sensation back a couple of steps. It still doesn't feel great but it takes the edge off of it. And like the morphine, I did find myself getting a little foggy in the head as a result of taking it. So I did opt out of the nausea medicine when the nausea wasn't too bad. But I definitely did take that medication more frequently than the morphine.

Day 10 - Thursday September 15

The team ordered a CT scan with IV contrast for the morning. By the afternoon, the team told me that the contrast study from the previous day and from today showed that some of the contrast dye did make it into my colon but some was still trapped in the small bowels and that there were indications of looped bowels suggesting obstruction. It was likely I had some combination of small bowel obstruction and post-operative ileus. Whether one proceeded the other was not clear but the treatment for both was the same: NG tube and watch and wait. Surgical intervention would only be called upon if strangulation occurred.

Day 11 - Friday September 16

Up to this point, I had been given various saline solutions with dextrose to keep me hydrated and supplied with energy. However, this is not a complete nutritional profile. Since it was clear I would not be leaving anytime soon, provision needed to be made for me to receive total parenteral nutrition (TPN). Since this material cannot be delivered by the standard peripheral IV, a peripherally inserted central catheter (PICC) line needed to be installed.The specially trained technician swabbed my arm with disinfectant, laid out the sterile materials, visualized the vein in my arm with the ultrasound and threaded the catheter into the vein and eventually ending in my heart. Total time from beginning to end: 20 minutes. During this hospital stay, one song I learned in high school came to my mind during the many moments of discouragement. It is a simple song but it redirected my eyes toward God and sustained me.

Matthew 11 (Wes Terasaki)

Come unto me, all who are weak 
Weary and heavy laden 
Gentle am I, humble in heart 
And you shall find rest for your soul.

All things are given unto those who believe 
Princes and lowly ones His blessings receive 
And just when I think that means everyone but me 
Jesus comes beckoning to me 

Enter the holy gates just as you are 
No need for a happy face, just come with your heart 
And Jesus will bring us a joyful melody 
If only His calling we heed 

We are His little ones, children of God 
Children and fellow heirs of His kingdome come 
And we share the greatest love the world has ever seen 
Here in the Lord's family 

Day 12 - Saturday September 17

The TPN bag was hung this evening. One bag had amino acids for my protein needs along with vitamins and minerals and a much higher percentage dextrose (sugar for calories) compared to the regular saline/dextrose IV bags. The other bag contained lipids and phospholipids.

UPDATE: Revisiting this blog post 1 year after this experience, I thought I'd mention a bit about the nutritional situation. The doctors went to TPN because they knew I would not be eating food anytime soon. The saline mix plus sugar IV that I had been receiving maintained my electrolyte balance which is absolutely essential as NG tube suction involves the loss of electrolytes that if not replenished would have potentially fatal consequences. At a nutritional level, by this point, the sugar in an IV is not enough nutrition. At this stage nearly 2 weeks into my hospitalization, my body had run down whatever stored sources of sugar I had, burning fat reserves to provide enough calories to keep various bodily functions going, and beginning to break down muscle to keep my supply of protein up for other higher priority functions. More nutrition was needed.

Day 13 - Sunday September 18

Rinse and repeat: the PICC line continued to give me TPN over a 24 hour period and the lipid bag was infused over 12 hours. NG tube output was measured during each shift and comparable replacement fluid was infused during that shift.

Day 14 - Monday September 19

Rinse and repeat: the PICC line gave me TPN over a 24 hour period and the lipid bag was infused over 12 hours. NG tube output was measured during each shift and comparable replacement fluid was infused during that shift.

Previously, the daily meds were: famotidinelovenox, and atorvastatin. One new thing added was Reglan, three times a day via IV.

Today, I was issued "patio privileges" which meant I could tell the nurse that I was going to take a walk away from the 8th floor and could even go outside to the patios of the hospital. Since I was still dependent on the NG tube suction, the recommendation be away for a maximum of 30 minutes. I didn't have the energy to take advantage of it on this day but would in all the subsequent days.

Day 15 - Tuesday September 20

Rinse and repeat.

Day 16 - Wednesday September 21

The day started and seemed headed toward rinse and repeat. However, today, the team decided to test if I can go without the NG tube suction. The NG tube stayed in but I was unhooked from the suction starting in the late morning. If I felt nausea or pain, I was to report it to the nurses and they would examine me and reconnect me to the suction if needed. Interestingly and positively, no nausea or pain arrived after many hours "off leash!"

Day 17 - Thursday September 22

By the afternoon, I had been off suction for over 24 hours so the team decided it was time to remove the NG tube!

Day 18 - Friday September 23

Liquid diet was started. Since my bowels had been asleep nearly 3 weeks, I was told take a sip every 10 minutes and don't push it. Just go slow.

Day 19 - Saturday September 24

More liquid diet. Take a bit every 10 minutes or so and don't push it. Just go slow.

Day 20 - Sunday September 25

Pureed food. Take a bit every 10 minutes or so and don't push it. Just go slow.

Day 21 - Monday September 26

Limited solid food. Take a bit every 10 minutes or so and don't push it. Just go slow.

The nutritionist came to check in on me in the morning. She anticipated I might be discharged on Tuesday. When I get home I was told to take it very slow. Wait a couple of weeks before adding raw fruits and vegetables.

The order was given to taper off the TPN. Because of the high dextrose content, they don't want to just stop the flow. The flow rate was cut in half for a couple of hours and then cut in half again for a couple of hours and then stopped all together.

By the afternoon, the PICC line was removed.

Day 22 - Tuesday September 27

Limited solid food. Take a bit every 10 minutes or so and don't push it. Just go slow.

By 1pm I was officially discharged!

Another song that gave me comfort and strength during my three-week stay was this old classic hymn.

Great is thy Faithfulness (Thomas Chisholm)

Great is thy faithfulness, O God my Father
there is no shadow of turning with thee
thou changest not, thy compassions, they fail not
as thou hast been thou forever will be. 

Great is thy faithfulness! Great is thy faithfulness! 
Morning by morning new mercies I see
all I have needed thy hand hath provided
great is thy faithfulness, Lord, unto me!

Much appreciation goes to the staff of 8West, Team "L," the surgical group, and all the professionals at Ronald Reagan UCLA Medical Center for their efforts in my care. I am grateful we can find such people to do this kind of work - they are amazing.

Also, much thanks go to family and friends who visited and supported through prayer me and my wife through this health episode.

And most of all, God has shown me so much love and grace through Mrs. Rambler who was my heartbeat and rock to lean upon during this extended stay in the hospital.

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.