My last Thursday afternoon and evening were quite the whirlwind — home to ER to OR to recovery to home in just under twenty-four hours. And good as new, despite a scare that probably would have killed me not that many years ago. Back when I worked in healthcare, first-hand patient stories always made the best market research. And since so many of my connections are still fighting that good fight — here’s one for free!
Woke up Thursday with some mild discomfort in my gut. Although I’ve been clear since my colectomy, years of dealing with diverticulitis made me dedicate a few brain cells to the issue while taking care of errands during the day. By afternoon the pain had gotten quite a bit worse and, more unsettling, focused in my lower-right side. This is not typically diverticulitis territory, but it is where the appendix sits. Huh. Time to take a closer look.
The Nolan family has gotten a lot of care at Overlake Hospital over the years. Along with the city of Bellevue, Overlake has grown dramatically since our first kiddo was born — in many ways for the better, and in others not always so much. But it’s hard to beat the convenience of a hospital ten minutes away, so it’s still our go-to. I drove over, successfully navigated into a tight little spot in the garage, and headed upstairs to the ER.
Waiting Around, Act One
Check-in and triage were fine. It wasn’t particularly crowded, but nobody was going to call Code Blue over a tender belly, so I settled in to wait with my book (a worthwhile one by Kara Swisher). My fellow patrons and their families were scattered around the room, all looking up hopefully every time somebody in scrubs opened a door or walked by.
By far the worst part of the ER experience is the open-ended waiting. A few years ago I listened to an audiobook course about Emergency Medicine trying to figure out why it’s so terrible, and I didn’t really get a good answer. Of course it’s a tough environment to predict — new cases show up all the time, and some of them are going to take precedence. But it’s more than the waiting, it’s the lack of feedback that makes it awful — did they forget me? Should I check back in? I have to go to the bathroom, but what if they call me while I’m gone?
It would be super easy to post a status board, so all I can think is that ER administrators must have decided that not knowing is better than knowing. And maybe there’s some truth to that — it’d be pretty tough to stand by quietly with a hurting child while others jump the line, even if it is the right “big picture” call. But for me, especially at a time when people are reaching out to be cared for, I believe hospitals can and should do better.
Anyways, after about an hour I was called back by a great nurse (such an amazing profession). She correctly predicted that the doc would want urine and blood samples, so got those going while I … waited some more. When I finally did see a doc (actually a PA, but he was fine) we were about three hours into the process and he ordered a CT Scan. Then back out to a special part of the lobby, a kind of a no-man’s land with recliners set up in a maze of temporary screens. Settle in.
The Best ER Hack
If you’re at a hospital in the United States today, you almost certainly have access to an online “patient portal” (most likely Epic’s MyChart). Thanks to a lot of folks who pushed this rock uphill for many years, just about all the information about your visit is available in the portal, in near real-time. This includes test results, visit details, even provider notes.
I can’t recommend this strongly enough: Make sure you have access to your patient portal during your time at the hospital! If you haven’t set things up ahead of time, use your wait time to do it, either by installing an app or just using the mobile browser on your phone. The folks at the front desk should be able to help if you need a hand.
Because of MyChart, I was able to see that my test results had come back. I had blood in my urine and a bunch of markers for infection in the blood — so something was up, albeit not clear exactly what. Even more important to my sanity, I could see that the CT Scan order had actually been sent to the imaging department and not lost.
After another hour and a half somebody called my name into the maze, brought me in for the CT, and deposited me back in my recliner. I was getting dangerously close to the end of my book!
Waiting Around, Act Two (aka The Hallway)
After about another hour fifteen in my recliner, an ER coordinator hunted me down in the maze and brought me back into the ER proper, leaving me in a side chair in the hallway with assurances that “somebody” would come by in a few minutes. This time the wait wasn’t actually that long — about fifteen minutes, during which I had this text exchange with Lara:
- Me: Assume must not be actively dying or would warrant not the hall.
- Lara: It’s appendicitis. I can see your chart.
- Me: Ah sh*t there it is.
- Lara: Also u have a notably small bladder but I think we knew that.
- Me: Rub it in.
Right about this time, a “doctor-looking” guy came up and asked if I was Sean. I confirmed I was, and asked if there was anything other than surgery for appendicitis. He startled a bit and asked me how I knew the diagnosis. Remember how I mentioned the value of having real-time access to your chart?
Anyways, the answer to my question was no, and he left quickly to make sure they could get an operating room ready right away. A couple of minutes later, the coordinator reappeared and said “I can’t find a wheelchair but you’re supposed to be upstairs in five minutes. Can you walk ok?”
And we were off.
Punch it!
As we walked out of the elevator, a nurse (who I met later as Nancy) went jogging past saying “They told me you were bringing a bed, now I have to find one.” We kept going down the hall to a mostly empty room where I met two more nurses, Lolo and Michelle. You know that scene from The Princess Diaries where Mia is getting transformed by an army of stylists all working on hair, nails, makeup, etc. at the same time? This was me but kind of in reverse. From about 8:30pm to 9:15pm, in no particular order (it was all happening at once), the team:
- Found a bed
- Got me changed into a gown and hair cover
- Collected my clothes and book into a bag
- Sterilized my body head to toe
- Shaved my abdomen (and vicinity!)
- Had me gargle with chlorhexidine and swabbed a bunch of iodine goo up my nose
- Itemized the contents of my wallet and pockets and sent it all to a safe somewhere
- Had me sign a bunch of consents
- Took at least a million vital signs
- Administered IV antibiotics and other goodies
- 2x reconfirmed my complete medical history and corrected the pharmacy on file
- Helped me video call Lara to tell her I was going into surgery
- Had me talk to the anesthesiologist about his plan
- Hooked up leg compression sleeves
- Attached me to a warm air blower of some kind
- Let me use the bathroom
After all of this they dimmed the lights and I just kind of hung out for about twenty minutes before being wheeled into the OR itself, where I met some more staff and they had me climb onto the operating table. The oxygen mask went on, I started some deep breaths and counting backwards and, and I’ll defer to MyChart for the rest because I was out cold:
I injected a few cc of 0.25% marcaine to the LUQ abdomen and made a small incision. I inserted a Veress needle to enter the peritoneal cavity. I used the saline drop test to make sure its correct location. I then insufflated the peritoneal cavity with carbon dioxide and achieved 15 mmHg. I made a 12 mm infra-umbilical incision and inserted a 12 mm port under direct visualization with 10 mm camera. I inserted 10 mm 30 degree camera, and inspected for any injury or bleeding while gaining access. There was none. I removed the Veress needle. I placed a 5 mm port in the suprapubic area and another 5 mm port in the left lower abdomen. The patient was then placed in the Trendelenburg position with the right side up.
The appendix was inflamed but without perforation. It was located inferior and lateral to the cecum. I grasped the tip of the appendix with a Hunter grasper, and ligated the mesoappendix with Ligasure. thereby leaving only the appendix attached to the cecum. The appendix was then stapled at it base with a white load stapler. The specimen was placed in an Endocatch bag and extracted through the 12 mm umbilical port. I irrigated the peritoneum with normal saline. The staple line was intact and hemostatic. The surgical count was correct. I closed the 12 mm port using a zero PDS tie and the Carter Thompson device. The 5 mm ports were removed under direct visualization and the peritoneal cavity was deflated. The skin incisions were closed with a 4/0 monocryl stitch. The patient tolerated the procedure well and was extubated and transferred to the PACU in a stable condition. I was present throughout the entire procedure and performed all the portions myself.
The sheer volume of technology in these two short paragraphs is almost beyond comprehension:
- A Veress needle is used to access the abdomen and inflate it with carbon dioxide. It has a little spring-loaded tip that covers the sharp end as soon as it enters the cavity so that the surgeon doesn’t accidently poke other important stuff in there.
- The “saline drop test” (aka “hanging drop test”) helps the surgeon know that they entered the abdomen correctly. A drop of saline should be sucked into the inserted Veress needle because our abdomen apparently holds negative pressure; if the drop stays on the surface, placement is incorrect.
- I first encountered the Trendelenburg position during my colectomy a few years ago.
- A grasper is a long thin tool that is used to manipulate tissues during laparoscopic surgery — the “Hunter” style seems to have a particular toothed gripping end for traction.
- LigaSure is used to cut and automatically seal tissue — in my case it was used to remove the mesoappendix that surrounds and holds the actual appendix.
- A stapler is used to, well, staple tissue closed — for the appendix, this both separates the organ and ensures it’s closed up.
- The Endo Catch bag could not look more like a little fishing net.
By 11:15pm I was awake in recovery, and by 11:30pm I was in a bed two floors up, ready to call it a night. Actual miracles.
Waiting Around, Act Three
I actually slept pretty well, getting up for good about 6am. My roommate Hank was a friendly older guy working through a boatload of challenges, but he too had a pretty restful night, apparently the first in weeks after getting some UTI relief. We chatted a bit, then he had breakfast while I caught up on my chart. By 7am the ER surgeon on shift came by to see how I was doing — which was surprisingly fine. She said if I ate something without puking it back up, I’d be good to go by 9am.
Challenge accepted, I dutifully (and successfully) ate half an omelet, then unplugged my IV pump from the wall to take a walk. In my limited time as a hospital in-patient, I’ve found no better way to pass the time and feel less awful than to walk around. Because this particular ward was pretty small — a loop of maybe thirty rooms — I got to know it well. Down to the big wall of windows, cut back up the hall to the back elevators, past the nurse’s station, out past the coffee machine and public elevators, back by my room. And again, and again. Overlake participates in a program for local artists, and I enjoyed the display of geometric/abstract pieces by Ann Reynolds, who I can’t seem to track down online.
Unfortunately, the hospital settled back into its comfortable ways. 9am rolled on by, as did 10am, 11am, 12pm, 1pm and even 2pm before I was finally discharged. Really? This seems suboptimal for everyone involved. At about noon while walking a circuit (now in street clothes in a passive aggressive attempt to move things along), the ER surgeon saw me and asked “What are you still doing here?” There was no good answer.
But I did finally make it home — and despite all the wasted time, with sincere thanks and appreciation to the institution, docs and nurses for keeping me safe. The technical side of medicine, especially what can be done with surgery and reconstruction, is the very definition of miraculous. If only we could do as well with payments and patient experience. Someday.