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Tuesday, December 16, 2014

Colonoscopy Notes

Colonoscopy is an  AmericanCancer Society recommended procedure for men and women over the age of 50 who have an average risk of developing colorectal cancer.  The results of one such procedure are documented below:  Apparently all is not particularly rosy in South Carolina when it comes to a patient's ability, under state law, to obtain damages for mistakes, or accidents resulting from the Doctor's failure to follow that most basic of all requirements of the Hippocratic Oath, "above all, do no harm."  Harm seems to be acceptable in South Carolina so long as it may be defined as a "known complication" of a given medical procedure.

Of course traffic accidents are a "known complication" of driving, are they not? Still, if someone T-bones you at an intersection while you are proceeding to negotiate a green light, you will have the opportunity to seek legal recompense.  Of course you are not a protected species as is, say, a colonoscopist whose actions in performing his task may be enabled and made sacrosanct by our state legislature under its legislation covering doctors and their insurers in malpractice situations. 

The following "Colonoscopy notes" describe a procedure done 10 September, 2012, at Aiken Surgical Center, in Aiken SC by Dr. Afsar Waraich the physician; Stephen V. Geddes the patient and writer.

                                    Colonoscopy notes 

I arrived at Aiken Surgical Center at 1:45 PM, a bit more than one hour (per instructions) early to fill out needed paperwork.

At 3 PM I was taken to preop.

A short time later I was taken to the procedure room.  Dr. Waraich and his anaesthesiologist were there.  They administered a general anaesthetic and I went "under."

Things happened.

About 4:00 to 4:45, I estimate, I was returned to preop, now the recovery area.  When asked how I felt, having no pain, I said fine.  I may have mentioned bloating--I don't really remember.  If I was asked about it, I would have answered to the best of my ability, I'm sure.

About 5 PM, the closing time for the Center, I was wheeled to my car.  The nurse asked me how I felt.  I told her I felt a bit bloated.  She said "That's the gas.  It will pass."  My wife then drove the two of us home.

After two hours with no passage of gas, feeling, essentially, as I did when I left the Surgery Center, I called Dr. Waraich.  He told me to give myself an enema.  This I did, sitting on a commode.  The only problem was the water ran out of me as fast as I squeezed it in.  I have given enemas before, and this never was a problem.

I called Dr. Waraich, about 8PM, and explained the problem.  He told me to give myself another enema, but this time to lie on my side as I was giving it.  He also said if I felt nauseous or feverish, to go to the ER.

As my wife prepared a bed, laying down plastic and towel material, I tried to push the gas out, sitting on the commode.  I "pushed" extremely hard.  I was finally successful (I really did not want to give myself an enema on my bed.)

I called Dr. Waraich back and told him of my success.  I told him I was now "farting like a racehorse" (somewhat something of a mixed metaphor, but I think he knew what I meant.)

I sat back down on the couch and continued to vent gas while watching television.

About 10 PM I got up to urinate.  I found out as long as I sat on the couch fairly quiet, I felt fine.  Getting up changed that.  My innards definitely felt bad.  I told Jennie we needed to go to the ER.

About 10:20 we were at the ER at Aiken Regional Medical Center.  Vitals were taken, and I told them I needed to lie down (less pain.)  Trish, a friend, was on duty as nurse assistant(?)  ER Doc Garrett listened to my symptoms--very full gut (still full of gas?), crampy, right shoulder hurting.  He said that might be from gas in the body cavity.  He ordered a CT scan, a morphine shot, a quart of gatoraid with iodide.  Got the scan, through the donut hole.

Maybe the morphine took over.  In any case, I met my surgeon, Dr. Chase.  He is not sure where the problem is and needs to take a look.  He will go in laparoscopically, and find and fix the problem that way if possible.  He may need to make a larger incision.

Midway through the surgery, his findings were  passed to wife Jennie.  The larger incision was needed.  A 2 to 3 inch tear was found in the caecum (cecum.)  Repair was effected by removal of the cecum with the attached appendix, and the ileocecal valve, and a bit of large intestine.  The small and large intestines were then joined together.

I was taken to room 402 where my stay was uneventful.  Dr. Waraich came by a couple of times--we didn't discuss the problem.  Dr. Muniz, my GP, came by at my request, as did Dr. Chase.

I was discharged on 15 Sep.

Thoughts on the above:

1)  At Aiken Surgical Center, I was the last patient of the day.  My leaving coincided with the center's closing time.  If degassing was attempted at all, perhaps it was not done with much care since the need to close the facility was one concern and the discharge of the "room gas" was apparently expected to be something that would occur as a matter of course.  Why CO2 was not used for the procedure, a state of the art method used as a matter of course in many facilities to minimize post-procedure difficulties for the patient, is not known.  It was never discussed with me as an option, and the use of CO2 was something I learned about much later.

2)  I never told anyone at the Surgical Center I had any pain because there was none.  I did feel the bloating, though, in my gut.  I experienced no pain until after I had forced some gas out of my body by pushing--the same thing I would have done had I had a recalcitrant, too dry fecal discharge due to some unavoidable delay in being able to access or use a restroom coupled perhaps with a too-high-in-fiber diet the day before.  Never before had I had any difficulty discharging any gas that may have accumulated in my intestine--probably because I had never before had my gut pumped full of air and a sigmoid volvulus generated by the combination of the gas and, perhaps, a rather thoughtless, perhaps hasty withdrawal of the colonoscopy instrument.  Why a sigmoid volvulus?  Well, some sort of obstruction was keeping the air in, and there was no significant fecal material there--it had all been cleaned out by the pre-colonoscopy diet and purging requirement.  What else, but a twist of the sigmoid, the last stage of the large intestine prior to the rectum and anus, would have prevented the enema from going in while preventing the gas from going out?

3)  If I had been told not to try to force the gas out, to let it come out on its own accord, that is what I would have done (of course, it wouldn't have worked.)  If I had been directed to go to the ER for intubation to get the gas out, that is what I would have done.  Lacking instruction, I did what I knew how to do--I pushed.  While everyone I have told this to has thought it was improbable, I think I blew a hole in my cecum trying to get Dr. Waraich's gas out.  Dr. Chase's notes say the cecum appeared to be beat up and the wound he found was described as a 3 inch longitudinal serosal tear with no definite penetration and a mucosa that appeared beat up. He also states there was pneumatosis of the cecum.  Could the colonoscopist have done this and been unaware of the damage he caused? Doubtful.  As a matter of fact, there was a picture of the cecum in Dr. Waraich's report on the procedure.  Was the problem my fault?  Truth of the matter is this:  Dr. Waraich put the gas in there, and, in retrospect there appears to be no doubt he should have removed it as part of the procedure. The Doctor's  "informed decision (or guess)" that it would be OK to discharge me without deflating the gut (what apparently happened,) perhaps to avoid overtime payments to the Surgical Center (I left at "quitting time"), was an informed mistake.  Had he left a glove in there, or a piece of the colonoscopy instrument, there would be no question as to his culpability.  The fact that the material he left there was in the gaseous as opposed to a solid state should not relieve him of his responsibility for what happened as a result of his "informed decision." The fact that I worked hard to push the gas out is immaterial, since I received no instructions to the contrary--I was only told, "it will pass."

What damage was really done?  None, some would say, unless you count having to take a dump several times a day instead of the usual once.  Unless you find yourself walking a trail and have to take a dump but cannot due to the nearness of civilization.  Unless you are in the middle of a Walmart when the need happens and you find all the stalls in use.  The looseness of my bowel material due to the lack of a cecum, the place where much of the water is  removed (it has the least thickness of all of the bowel, about 1mm) is something I have had every day for the last two years and it is something I will have till the day I die.  I have "messed my pants" more than a few times.  I consider this a major inconvenience, and feel some sort of compensation is due.  Put yourself in my place.  What would you expect.  The Doc was paid for his work, defective though it may have proved to be.  His insurance should pay for my inconvenience and disability, just as certainly as his automobile insurance would pay if he had accidentally caused a vehicular incident that left me in this condition.  The fact that I am not dead or dismembered should not relieve Dr. Waraich and his insurance company of any responsibility to pay whatever the legal system might consider reasonable--be it a dollar or the maximum allowable amount per our state legislature's highly lobbied law limiting payments for malpractice. 

Given the relatively small amount of compensation available per the law, and the costs for filing such a lawsuit, it seems to me that the legislature should be notified that their law is unfair to the person having what should be a small settlement and having little means to pay, up front, the relatively large amounts required to obtain legal and medical counsel in order to be able to simply file and prosecute a claim.  Justice should not be something that must be bought.  It is, though, or at least it was for me, under the terms of the state law on malpractice suits. The legislature lost sight of this when they wrote their law.  I experienced more than just difficulty in finding a lawyer to take my case because it was not a slam-dunk, and they do not find the legal potential for profit to justify their participation.  What I experienced was a total inability to find a lawyer willing to take the case. 

Because of these considerations, I feel, instead of no consideration at all, I should have been compensated with the maximum amount available by law--$375,000 (and expenses) to: 1) Notify the legislature they should re-examine this law for reasonability understanding the difficulty the average person will experience should he need to try to obtain justice given the current constraints of the law and; 2) notify insurance companies, especially Marsh, Inc. of JUA, that they are in a position to determine liability and should so do and not simply deny potential claimants a settlement--their stated position--knowing the economics of filing would cause many of them to dry up and go away regardless of the justness of their claim;  and, 3) while I know the economic costs of buying supplies to use in dealing with my disability is relatively small, the fact that almost anyone would totally dislike the added need to deal with their bodily elimination function, the wiping and the washing, etc., as often as I am forced so to do is not something I would wish on you or on myself, or even on our legislators.  My condition makes everything I do more difficult:  shopping, traveling, enjoying our parks, going to meetings, e.g., everything I might do is liable to be interrupted in order that I deal with the problem Dr. Waraich has "given" me.

Well, as I said, I was unable to obtain legal representation.  Specifically, I contacted at least five legal firms specializing in malpractice cases and none would take my case.  I contacted several "expert witnesses" and found they would only speak with a plaintiff's legal representatives.  I had two years to file a complaint, under the terms of our state law, and was unable to so do.  So, I guess I must bear the burden of my condition with no compensation.  Is this fair?  Our current state legislature thinks so.  I think they all should be fired for their lackluster performance in crafting this law (of course they probably did little to craft anything.  They seem to have passed a law that was provided by legal lobbyists for the doctors' insurance firms.)  I guess what we had when this was passed was a medical-legislative alliance, something akin to the industrial-military complex President Eisenhower warned us about.  Goodness--where do you go to find a good President (or, on the state level, a good Governor) when you need one.  

Oh, well--guess I've gotta stop.  I need to go take a "waraich" (sorry, Mr. Craps, my condition requires a slight redefinition of the vernacular, for me if for nobody else.)  And, Doctor, should the term catch on, you have only yourself and your insurance company to blame.  Think it'll catch on?  Well, strange things do occasionally happen, but in this case probably not--the four letter term seems to be the norm for material such as this.