Behind Closed Doors: Surgery with an “Appy” Ending

If ever there were a physical example for proof of the argument in favor of evolution vs. creationism it would most certainly be the human appendix. What kind of spiteful, ill-humored God would purposefully place this useless and trouble-making stump at the beginning of our colon? In our ancient incarnation as ground dwelling pre-historic mammals, the appendix undoubtedly played a useful role, as it does in modern-day rodents and other such buck-toothed chewing machines. However, the relentless march of genetic progress, random as it is, has relegated the appendix, along with other vestigial structures such as the coccyx, the erector pilae muscles, and the plica luminaris to the trash heap of human appurtenances. It would be nice if the appendix minded its own business and didn’t trouble us. But like an unsolicited sales call, it troubles us to no end.

Appendicitis is inflammation of the appendix, and is a lot more common and potentially life threatening than one might think. Historically, the diagnosis of an inflamed and burst appendix was often a death sentence. Its rupture causes exposure of the contents of the bowel to the unprotected inside of the abdomen resulting in a condition known as peritonitis. This can lead to overwhelming sepsis due to gut bacteria in the bloodstream. Untreated, death will occur in relatively short order.

The first recorded appendectomy was performed in 1736 by French surgeon, Claudius Aymand, who operated on an awake 11 year-old for an appendix perforated by a swallowed straight pin. In 1804, the only person to die on the entire Lewis and Clark expedition was Sergeant Charles Floyd, due to an attack of suspected appendicitis.  At this time surgical anesthesia did not exist save for a shot of whiskey and a stick to bite on, nor did reliable surgery, and there were certainly no antibiotics to be had at any price. It wasn’t until the latter part of the 19th century with the advent of general anesthesia and more refined surgical technique that it was possible to treat and cure acute appendicitis.

About 250,000 cases of appendicitis occur annually in the United States, and the lifetime risk of an appendectomy is estimated at 12% for males and 23% for females. Thus appendectomies remain a common procedure.  In my family, both my wife and my daughter have had appendicitis followed by emergency surgery. Dana had hers in the first trimester of her third and last pregnancy. Kate had hers at the tender age of four.

As is the case in many doctor’s families, the three “Ds” of diagnosis were critical in identifying the problem. The first is “downplaying” of the complaint. “Are you dying? Cause a lot of my patients are…” is a common refrain in my house. Dana woke up in the middle of the night with vague peri-umbilical abdominal pain. “It’s just gas, go back to sleep!” I said and rolled over. Despite sitting in a warm bath for the rest of the night, Dana felt worse in the morning. She vomited and her pain had localized to the right lower quadrant of her abdomen. I said, “Maybe it was something you ate. I hope you feel better. Gotta go to work! Call me if it gets worse.” and I hurriedly rushed out the door to take care of my first case of the day. Fortunately we have an amazing friend we call Saint Gina. She is a nurse, and a super-mom, and as practical and able as they come. Dana called her to look after our boys because she was feeling too sick to get up. As soon as she arrived, Gina took one look at Dana and said, “You are going right to the hospital!”

The second “D” is “denial.” While I briefly considered that Dana’s constellation of symptoms might be appendicitis, I was far more worried about an ectopic pregnancy as that was entirely possible given her gestational age of ten weeks, a common time for such a problem.  In retrospect, it is good advice for physicians to leave the diagnosis and treatment of family members to others far more objective, and thus more competent. A surgical consult and an ultrasound revealed both a healthy intrauterine pregnancy, and a grossly swollen appendix. Therefore, the third “D” is for “dumb-ass!” which is what I felt like after the correct diagnosis was made. Fortunately, Dana underwent an uneventful appendectomy under spinal anesthesia, in order to minimize exposure to anesthetic agents to our developing fetus that eventually became our lovely daughter Kate.

As luck would have it – both bad and good – Kate would soon emulate her mother. Early one evening when she was four years old, we decided to see “Harry Potter and the Chamber of Secrets” at our local theatre. Kate had been feeling a little poorly for most of that day and was a touch irritable. For Kate, irritable meant that she smiled only 95% of the time rather than 100%, so I thought a movie would cheer her up and off we went.  She sat on my lap spellbound (no pun intended) with the film. I noticed she felt a little warm, and was aware that every time my hand rested on her stomach she stiffened. As we walked up the aisle at the end of the movie, she seemed to limp a bit. By the time we got home, I could tell she was sick. I laid her down on the kitchen table and proceeded to play surgeon. “Does your tummy hurt?” I asked. “Yes. First it hurt in the middle and now it hurts down here.” pointing at her right lower quadrant at a place called “McBurney’s point” named after the surgeon who initially described the signs of appendicitis. Textbook answer. “Does it hurt more when I press, or when I let go?”  I gently pushed then released the spot to which she pointed. She winced as I let go, and with a sinking feeling I knew we were going to the hospital. The latter sign indicates an inflamed appendix and a resultant angry peritoneum, the lining of the abdominal cavity.

It was now pretty late in the evening, and the emergency waiting room at our local hospital was totally empty. Literally, crickets chirped. Nevertheless, we sat for what seemed to be an eternity. Finally, I couldn’t take it anymore and in my best doctor voice I approached the intake nurse and said, “Listen, my daughter is febrile, has peri-umbilical pain that has localized to the right lower quadrant, has rebound tenderness and is guarding. Could we please see the doctor on call?” She looked at me; her expression narrowed, and with a voice dripping with condescension said, “My! We are using big medical words, aren’t we? Are we a nurse or something?” I resisted the urge to push her smug face in and replied in as level a Clint Eastwood voice as possible, “No, we are a doctor or something. Should I use smaller non-medical words so you understand them?”  I was being a total jerk but didn’t care. This was my daughter after all.

Once in the ER, a quick urine test was negative and a blood test revealed a high white count. Ultrasound again clinched the diagnosis.  Kate was a trooper through it all, bravely enduring a urethral straight catheter and a needle poke for a blood sample without so much as a whimper. Because our local hospital had neither pediatric surgeons nor pediatric anesthesiologists, and I felt more comfortable on my home turf, I arranged for a friend, Mike Harrison, one of the best pediatric surgeons in the country to see her immediately in the city. Surgery was quick and went well. Her appendix was nearly ruptured and I considered myself lucky to live in an area with so much choice and talent available.

It is truly amazing that such a little vestigial tube of flesh can cause so much trouble, but it most certainly does. Dana remembers her appendectomy as the time that our two elder boys, then age two and four were given free rein in the kitchen and on the computer. As she lay in bed suffering while her doctor husband was taking care of his own patients instead of his ailing wife, they went to town on the snack drawer. Then primed with sugar, they printed hundreds of pictures of Pajama Sam, Sly Fox, and Putt Putt the talking car, heroes of their favorite “Humongous Entertainment” games.

Kate remembers enjoying Harry Potter a lot despite the pain in her stomach, her quick trip to the hospital where daddy worked, and the popsicles after surgery. I remember being humbled and thankful that we live in a time and place where we have immediate access to such wondrous medical technology, and an appendectomy is considered minor surgery. Though perhaps I should reconsider that final thought, as minor surgery is always something that happens to someone else.

Jeffrey Swisher, M.D.

San Francisco, CA

Dr. Jeff Swisher is an anesthesiologist who practices in San Francisco. He graduated from Stanford University with degrees in International Relations and Medicine, and lives in Marin County with his wife Dana, three teenagers, two large dogs, and a merciless take-no-prisoners black Bombay cat named Gin. He also plays in a middle-aged-guy rock band named “Blatant Malpractice.”

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