Dear Dr. Roach: Two months ago, my husband fell down a flight of stairs and fractured six ribs and a vertebra in his neck. He is 65 years old and was in good health before this accident. He was hospitalized in a level 1 trauma centre and was doing well until 10 days after the accident, when his abdomen became very swollen. He was rushed to the emergency room and was diagnosed with abdominal compartment syndrome; he needed emergency surgery to address the swelling of his major organs. He had an ileostomy and later needed another three major surgeries, including one for a collapsed lung. Breathing issues have been a major problem; he had a breathing tube inserted for three weeks. His voice has changed. No more surgery is planned, and he is now in rehab. What causes the abdominal compartment syndrome that did so much damage, and how could it have been prevented?
B.E.
A “compartment syndrome” is when the pressure inside a closed system becomes high enough to affect the contents of the compartment. A compartment is a section of the body walled off by anatomic structures.
I am most familiar with compartment syndromes of an extremity. For example, there are different compartments of the arm and leg. Severe damage to a muscle can cause it to swell, increasing the pressure in the compartment so much that not enough blood can get to the injured muscle. It is a surgical emergency, requiring the opening of the compartment.
The abdomen itself is a compartment, with the anatomic structure being the lining of the abdomen. There are many possible causes for abdominal compartment syndrome. Trauma, such as what your husband suffered falling down the stairs, is among the most common. Surgery, sepsis, severe liver disease and burns also may cause ACS. ACS can cause compression of the lung, as you note. With poor blood supply to the intestine, it can lead to tissue death.
ACS is hard to diagnose, as it most commonly happens in critically ill people who cannot communicate. The physical finding of a tense, distended abdomen suggests ACS but may have many other causes, so the physicians do not always think of this condition. It’s not common; only one per cent of trauma patients have the condition.
ACS is diagnosed by measuring the pressure in the abdomen. The easiest way to do this is by measuring the pressure of the bladder. Treatment is to open the abdomen to relieve the pressure, and the abdomen usually is left open while the organs recover. The earlier the syndrome is considered and diagnosed, the better the chances of recovery without permanent organ damage.
Dear Dr. Roach: When at the office for a routine checkup with an appointment, how long should a patient be kept in a room waiting for the doctor? My doctor thinks it is OK to be 20 to 30 minutes past the appointment time. My last office visit was 30 minutes over time, making me late for another appointment. Do patients have any recourse or a patient bill of rights?
G.G.
I think a doctor should be on time, unless there is a medical emergency. A patient’s time is valuable, and I think being habitually late is unprofessional. Getting the first appointment of the day is sometimes helpful, but your ultimate recourse is to find a doctor who will treat your needs more respectfully.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu.
