Lakeside Medical Musings

“All Bleeding Stops”

When I started medical school in 1975, a memorable speech by one of my professors centered around this attention-grabbing statement:  at least 50% of what we would learn during the next four years would eventually turn out to be either irrelevant or just plain wrong.  He said this would happen for three major reasons: new diagnostic tests would make the ones we were now learning obsolete; medications and treatments would continue to improve and completely change the way medicine was currently being practiced; and, finally, much of what physicians once thought to be true would, ultimately, turn out to be false.  From my many years of experience, I can tell you that this was a completely true statement, although I heard it with great skepticism, as well as dismay, at the time.

Today I am writing about peptic ulcer disease (PUD) and how much our methods of treatment have changed over the course of my career. This disease is a perfect example of my professor’s 50% rule.

To get a feel for what a peptic ulcer is, think of a cold sore that occurs in the mouth. When these ulcerated areas occur in the stomach or small intestine, they are called peptic ulcers. These are frequently much deeper – and larger — than mouth ulcers, but there are enough similarities to carry the comparison.

So, once again, let’s set the WayBack Machine to early September in 1975; the location is Augusta, Georgia at The Medical College of Georgia, the state university system’s medical college. Power up, Mr. Peabody!

I was in a small conference room (picture a Dead Poet’s Society-style classroom with a large blackboard) with the three other medical students who made up the General Surgery rotation.   The elderly professor – he had to be at least 60! —   drew a picture on the blackboard of the esophagus, stomach and duodenum (the first part of the small intestine). He put an “x” at the spot where the stomach ends and the duodenum begins. The drawing looked something like this:

stomach

He said, “This “x” marks the spot for the majority of our treatment of ulcers. For the next month, you will learn about all the surgical procedures to address this common problem.” While we don’t think anything about it today, the single most common surgery performed in the 1970’s was for PUD, and the number of admissions to hospitals for problems related to PUD was huge. There were quite a number of different procedures that we learned to surgically treat ulcers, Billroth I and II, vagotomy, and pyloroplasty, to name a few. Ulcers had complications — besides significant pain — for the patient.  We treated bleeding ulcers, perforating ulcers, and gastric outlet obstruction, and they all carried surgical potential.  It seemed like my entire general surgery rotation was centered on ulcers, which was an accurate reflection of what the time period required of the training for general surgeons.

We were taught that excess acid was the cause of ulcers, and its treatment was to eliminate the source of the acid. ”No acid, no ulcers,” was the medical school refrain, but it turns out that this was only partially true. We have since learned that ulcers are actually caused by a specific type of bacteria called “Helicobacter pylori,” but we didn’t know that then.

Ulcers were diagnosed by an Upper GI Series, an X-ray study done while the patient drinks a Barium liquid.  (Endoscopy was still a futurist’s dream.)  The non-surgical treatment of ulcers was simple – Maalox, the chalky white, mint-flavored liquid that was dosed at the rate of two tablespoons every two hours.  It is difficult now for me to imagine patients actually ingesting so much of this medication, as one of the active ingredients in Maalox is the same as in Milk of Magnesia, so you can guess the major unintended consequence of the Maalox treatment.  When Tagamet  (generic: cimetidine) was approved by the FDA for the suppression of stomach acid in 1977, it ultimately changed the entire approach to ulcer treatment  and was such a significant step forward that it won the 1988 Nobel Prize in Medicine for its inventor, Sir James W. Black. On a side note, Tagamet was also a ground-breaker for me, not Nobel level, but fun nonetheless. In 1978, after learning about Tagamet in Pharmacology class, I read a newspaper article stating that Tagamet had received FDA approval, and I convinced my surgical professor to let me try Tagamet on one of my patients. I became the first person in the state of Georgia to write hospital orders for Tagamet.  Smith, Kline & French, the producers of Tagamet, actually flew a supply of the drug down to Augusta for my patient, as there was none yet available in the state.  Tagamet went on to become the first true blockbuster drug, becoming the Number One prescribed drug in the world by 1983. In the post-Tagamet world of gastrointestinal practice, ulcers were easily treated with Tagamet, the need for surgical intervention plummeted, and thus the complications that we spent so much time learning about disappeared.  One little pill, ingested four times a day, revolutionized the practice of America’s general surgeons in a decade. Today, it is extremely rare for me to see a patient who requires surgery for the treatment of ulcers.

But there was much more, treatment-wise, that changed, as well.   Mr. Peabody, now reset the WayBack Machine to the middle of the night, sometime in December of 1980. The location is the VA Hospital in Dallas,Texas, where I was the medical resident in charge of the ICU.

I was dead asleep, in spite of the miserably uncomfortable cots in the physician’s call room, when I was STAT paged to the ICU with the unwelcome news that my patient, Mr. Brown, whom I had admitted earlier in the day with an upper GI bleed from an ulcer, had begun to bleed again.  I rubbed my eyes and struggled into my white coat while I walked quickly to the ICU.  Paul, my excellent intern, was already on the case, and as soon as I walked into the cubicle, I saw Mr. Brown vomiting large quantities of blood.  Paul had already started IV fluids, requested blood from the blood bank, and had positioned a large basin of ice-filled water next to Mr. Brown’s bed.  “Do you have the tube?” I asked Paul, meaning the Ewald tube, and Paul, of course, had it ready to go.  An Ewald tube is a clear plastic tube about three feet long, about the diameter of a thumb, with multiple holes at the end.  This tube was inserted into the patient’s mouth, worked into the esophagus, and threaded down into the patient’s stomach. The tube was then held straight up above the patient’s head, and several large syringes of ice water were pushed into the tube to flood the patient’s stomach with ice water to, hopefully, stop the bleed. Finally, the outside end of the Ewald tube was repositioned and the now-bloodied mess of water was siphoned into a bedside bucket, much like siphoning gas out of a car. There is nothing at all that was neat and tidy about this archaic, miserable, awful procedure, and the aftermath looked like a cross between Texas Chainsaw Massacre and the melting of the polar ice caps. Ice water and blood was spattered and pooled everywhere in Mr. Brown’s cubicle.  He was shivering uncontrollably from the forced internalization of ice water, and he was extremely agitated from having such a large tube shoved down his throat with no sedation.  Paul and I were not in much better shape than the patient, as our hands had been plunged in ice water for 30 or 40 minutes as we lavaged the patient’s stomach and watched the water for its characteristic turn from blood red to light pink.  There was adrenaline blasting through the arteries of everyone in the room, patient, doctors, and nurses.

There is an old adage in medicine, “All bleeding stops.” (The implication being that you either fix the problem or the patient dies.)  But when you are shivering, wet, and covered with blood, and working frantically on a patient, it doesn’t seem as if it ever will. When the water finally did turn pink, we knew Mr. Brown’s bleeding had stopped. Our shoes were soaking wet, and we were freezing cold.  We had to keep a heart monitor on the patient, but it was difficult to distinguish his heart beat from the muscle tremors of the shiver.  Physicians on the ice-water duty were always terrified that the patient would go into cardiac arrest because, if electrical cardioversion had to be used, everyone in the vicinity standing in wet shoes in puddles would get quite a shock.  By the way, in reference to last week’s blog post, none of us even considered wearing latex gloves during this entire procedure, despite the enormous quantities of blood and body fluids in which we were practically immersed.

This barbaric treatment—gastric lavage with ice water—for bleeding peptic ulcer disease did not work. We didn’t know that at the time, but the 50% rule that I learned in medical school held true, and we did this procedure over and over again until Tagamet changed the course of PUD, and the training of general surgeons, forever.

So if you suffer from indigestion today and are prescribed a medication for heartburn, or if you develop an ulcer and get one of the modern treatments of choice, be thankful that we have made such enormous progress.  You probably won’t ever need surgery, and you definitely won’t ever get the ice water torture that was standard procedure forty years ago.  Progress doesn’t always move us forward, but in the case of ulcers, what a difference a few years makes!

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