On Wednesday, February 22, he walked into the hospital at 7:45, just like any other day. He’s tall. Despite being younger than he looks in pictures, his hair is thinning near the top. He has it cut short.
It was Dr. Nicholas Mouw’s first day back from a very relaxing vacation somewhere warmer. In August, Mouw started his job as general surgeon at Sioux Center Health.
The patient log waited for him at the nurses’ station, anchored to a clipboard.
“How was your vacation?” asked Joanne Langeraap, Managing Nurse of Surgery.
“It was very nice; the weather was great,” answered Mouw.
Another nurse, rounding the corner, queried, “Where did you go again?”
“Nassau. In the Bahamas. It was a Sandals Resort; quite nice actually.”
Nurse Anesthetist Ron Haan emerged from a door across the hall, adjusting his surgery cap and pulling on his scrubs.
“Hey, how was your vacation?” he asked.
The log listed the names, scheduled procedures and other pertinent information for each patient Dr. Mouw would see that day. He looked at the page for a while, lifted it up, noticed that the backside was blank and let it return to rest.
“Four EGDs and a colonoscopy today,” he said.
The two procedures are similar. An esophagogastroduodenoscopy (EGD) is a minimally invasive procedure that involves inserting an endoscope through the oral cavity of a patient, down the esophagus, into the stomach and peeking into the first portion of the small intestine, the duodenum.
As an EGD starts in the mouth, a colonoscopy starts at the other end.
The first patient was elderly. “She’s been on a proton pump inhibitor for a couple weeks now,” said Mouw. Proton pump inhibitors are a class of medication that reduce the amount of acid the stomach makes.
This woman had come in with chest and stomach pain earlier in the month and ulcers were found just above her stomach—the result of excess acid eating through and irritating the lining of her esophagus. She was back to verify that the treatment was working.
“These drugs can have unpleasant side effects if used long term,” Mouw told the patient. “If you’ve improved I’ll put you on something a little milder.”
The next few minutes contained an overview of the procedure and an analysis of the risk. The most dangerous complication is a perforation somewhere along the esophagus or stomach.
“I’ve never caused a perforation and I don’t intend to now,” said the doctor.
Mouw left the room and headed for the endoscopy suite. Inside he was met by two surgery technicians. The first left to go fetch the patient.
The second, Kristin Haan, wore mint green scrubs. She was arranging items on the cart that carried the endoscope.
The “scope” looks like a snake. Its black with white bands every five centimeters. These markings help the doctor know how deep the instrument is inside the patient. The head of the scope holds a light, a camera (with impressive focal range), a water jet, the mouth of a vacuum line and an auxiliary port for a range of tools.
Following the head, the first 10 centimeters of the scope is motorized with stellar dexterity. The many joints in the shaft are actuated by the controller attached at the end of the scope held by the operator.
Ron Haan entered shortly after the first surgery tech left. He woke up the vital signs monitor and began preparing his potion of Propofol (a milky-colored sedative that stings when it first enters the arm through an IV).
Mouw donned a disposable blue gown that ties in the back to protect his business blue button down and teal, orange and white patterned tie from any fluids that may seek to stain. He pulled surgical gloves onto his hands and over the cuffs of the gown.
The patient rolled into the room on a bed, accompanied by the first surgery technician. She was prompted to roll on her side as Ron Haan hooked her up to the Propofol. He depressed the plunger and a few milliliters of drugs entered the patient’s blood stream.
Meanwhile Kristin Haan was fitting a mouth guard into the patient’s mouth.
“It’s so you don’t bite me,” said Mouw. The half-conscious patient either didn’t find the joke amusing or was prevented from smiling by the mouth guard.
After few more milliliters of Propofol, it was time.
Mouw rolled the head of the scope in some lidocaine jelly he had just squeezed onto a gauze pad. Lidocaine, like Novocain, is a local anesthetic that numbs any tissue it contacts. The jelly, said Mouw, is better than any sore throat lozenge.
The snake entered the patient’s mouth.
The procedure is a high-stakes version of Mario Kart. Mouw used his free hand to push the scope down the throat of his patient. With his eyes on the screen showing the feed from the scope’s camera, his other hand twisted the wheel on the controller to steer the scope straight.
The patient’s tortuous esophagus made the journey down to the stomach a twisty-turny challenge.
The location where the esophagus feeds into the stomach is called the gastroesophageal junction (GEJ). In normal individuals, the GEJ occurs at roughly the same location that the esophagus passes through a hole in the diaphragm called a hiatus.
This patient’s GEJ was nowhere near her diaphragm.
“She has what’s called a hiatal hernia,” said Mouw, “where a portion of the stomach pushes up through the diaphragm and into the thoracic cavity.”
Since a portion of her stomach is above the tight hiatus that would normally prevent acid reflux, the hernia is likely the major cause of the ulcers around the patient’s GEJ. If the patient was younger, or the surgery less risky, Dr. Mouw said he would surgically repair the hernia.
For now, it looks like the medication is working well and the ulcers are retreating.
After a couple pictures and measurements were taken, the scope came back out the way it went in.
Mouw set the scope back on the cart. He snapped the string tying back his gown. With a serious of quick memorized motions his gown and gloves came off in one piece. He rolled them into a tight ball and discarded it in the trash.
Retreating to the surgeon’s lounge, Mouw recorded the procedure, team members and findings in his notes.
One down, four more to go.