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How a ruptured spleen saved a life

Of the many thousand operations I did in my surgical career, most were life-improving rather than life-saving. To me, life-saving implies immediate or imminent risk of death: gunshot wounds, stabbings, gastrointestinal bleeding or perforations, punctured lungs, and cracking a chest in the ER for a stab wound to the heart. Potentially life-saving but less dramatic is removing a malignancy that, untreated or treated later, would likely have killed the person.

Most patients on whom I operated eventually returned to the care of their primary physicians or an oncologist. Much as I loved long-term relationships with any of my patients, it was uncommon. Beyond a few months, I usually had no idea how they fared. It’s among the few things I regretted about my chosen life.

Last week, things changed, if only in one instance. After vacating the premises while my wife hosted her book group, when I returned, she said urgently, “You have to listen to this phone message.” Uh oh, I thought. My weekly political commentary in our local newspaper engenders a range of voicemail, most of them hypo-appreciative.

“Hello, Dr. Schwab,” it began. “This is (Jeff Jones, let’s say), in Salem, Oregon, and this call is long overdue.” I’d started my surgical practice there, moving to Everett forty-two years ago, largely to be closer to my wife’s parents and eight siblings, all of whom live nearby.

“You may not remember me,” he went on, “But you saved my life from a ruptured spleen due to metastatic melanoma, in 1981.” Oh, I remembered him. Nearly every detail. It was remarkable then; astounding to hear from him now. Melanoma is the deadliest skin cancer. But it’s also the most unpredictable.

The emergency room called on New Year’s Eve night, 1980. A man had arrived with severe abdominal pain, in shock. They’d done a CT scan before calling me, showing a ruptured spleen. My goal for celebrating a new year’s arrival has always been to sleep through it, but this was a good reason not to.

Having received adequate intravenous fluids, his vital signs were satisfactory when I got there, so we had time to stabilize him further; in his case, that meant transfusing about five pints of blood. By the time we took him to surgery, first case of 1981, he was pink, calm, and stable. I don’t recall whether his history of melanoma was mentioned preoperatively. If so, I’m not sure I’d have connected it. For one thing, it had been treated several years earlier.

I grew up in Portland. Our next-door neighbor, a friend, was, coincidently, the surgeon who’d provided Jeff’s original cancer care. The treatment rendered was, at the time, experimental. The presenting melanoma was on his arm, and, after standard wide surgical excision and removing the lymph nodes under his arm, he was given chemotherapy agents infused directly into the artery supplying the malignancy’s former location. There were no untoward consequences. Years passed.

After opening Mr. Jones’ belly, I cleaned out the expected large amount of blood. What I hadn’t expected were several golf-ball-size masses within his leaking spleen: melanoma, which had to have spread there before his initial treatment. Given their size, they were possibly his only metastases, culled from his bloodstream by his spleen doing its job; any others likely would have been equally large and easily detected. Nevertheless, I spent time, after removing the spleen, looking for suspicious areas, taking a couple of biopsies, and washing out his abdominal cavity with sterile water, which will osmotically explode free-floating tumor cells. After such a rupture, odds are they’d have been there. Recurrence was more likely than not.

When I checked him later that day – and, given commonly-heard fears, I hesitate to say this without emphasizing its particularity – he shocked me again. “I felt everything when you cut me open,” he said, accurately recounting the first minutes of conversation I’d had with the team. Assuming the anesthesiologist would be similarly dismayed, I later told him of it. “Right,” he said. “It was a ruptured spleen, so I only gave him paralyzing agents at first, so he didn’t crash on induction.” Unbelievable. He was totally stable, had been for hours. Alert, not in shock. As if it just happened, Jeff recalls the pain to this day. Inexcusable.

His recovery was smooth. After a couple of office visits, I didn’t see him again, but I’d recalled his exceptional case many times. Hearing from him decades later, in his 80s, having children, grandchildren, and great-grandchildren, was indescribably wonderful. I called him back, of course. Talked for a long time, about life, mostly. Sent him a copy of my book, too.

General surgery was hard work, physically and mentally. Eventually, it burned me out. But, because Mr. Jones thought to call, I’ll assume there are others out there, too, living lives they otherwise might not have had. Thanks, Jeff, for staying alive and letting me know.

Sid Schwab is a retired surgeon who blogs at Surgeonsblog and is the author of Cutting Remarks: Insights and Recollections of a Surgeon.

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