Free Air

Free Air.

Two words you never want to hear, specifically if it's followed by the phrase "under the diaphragm." You hear that, and it can only mean one thing... straight to the OR for an exploratory laparotomy where you get a vertical incision all the way down your belly to explore your abdomen for the cause of this "free air." Free air means that something has perforated or ruptured. Never good.

That patient I mentioned in my last post? My first patient on this rotation? The one I had to tell he had lymphoma? On of my FPs (favorite patient)? The one that was finally starting chemo and getting ready to be discharged? That one? His xray yesterday showed free air.

Every morning I walk into his room to ask him how he's feeling, and before I can even get the words out, he'll ask "How are you doin' this morning?" And he genuinely wants to know. Every evening when I check on him before I leave, he tells me to "you drive safe." Yesterday morning I walked into his room, and he told me about this belly pain. This belly pain that felt different from his normal belly pain. I listened. I looked at his belly. No guarding, no rebound tenderness = benign abdomen = no scary belly. His vital signs? Normal. We talked about and it thought maybe it was just one of the kidney stones they saw passing. A few hours later, the intern and I get a call from the oncologist asking us to get some imaging because they're worried about this belly pain. I thought, "Really? His belly was so benign this morning."

We go to check on him. We walk into the room and he's sitting on the edge of his bed, hunched over, breathing fast. I felt my heart beat a little faster. "Mr. P? Are you alright?" I check his pulse. A little fast, but not that much faster than he has been. We check his belly. Still no guarding, still benign, but very tender. We meet the rest of the team to round and I ask that we see him first. The senior resident and attending check his belly. Still benign. The resident asks me what I want to do. I tell her I'm worried about this pain. Let's get an xray just to be safe.

I didn't think anything would be on that xray. I hoped not. It came back "free air under the diaphragm." But his belly is so benign. Could it be bowel in front of the liver? It can't be free air. Let's get a CT and call surgery. As he is getting his CT, surgery examines his belly. Benign. They're not going to operate. Until they see the CT confirming that xray. Free air.

With the team rounding, I didn't get to see him before they took him to surgery. I wish I did. I really wish I did. Just to tell him that he was in good hands. Just to tell him that we were going to take care of him. Just to tell him not to be scared. But I didn't get to see him.

I check the operative note before going to bed.
"Massive ileal perforation" "partial right hemicolectomy" "partial distal ileectomy" "bowel left in discontinuity" "taken to the ICU on ventilator"
Words I didn't want to read.

He was so happy to be finally getting his chemotherapy and to almost be leaving the hospital, and now he's sedated, intubated, with an open belly lying alone in an ICU bed.