Warning: this post describes medical processes that some folks might find to be unappealing or “really freaking gross.” Just as a heads up.

Pre-medical folks are a special bunch. There aren’t too many people with whom you can have this interaction:

Me: Hey, Dr. P doesn’t have much for us anymore. Mind if I follow you around for a bit?

Graduated Postbac Working as a Scribe in the ER:  Sure. Not much going on here right now. Did you see anything interesting today?

Me: I got to watch them drain about seven liters of fluid from a guy with ascites.

Scribe: Oh really!? Man, I’ve been wanting to see that. I can’t believe I missed it!

The gentleman in question was a former alcoholic who reported having consumed somewhere around a twelve pack of beer every day for the majority of his life. He was utterly emaciated, skin hanging off a rail thin frame, with a stomach that was so distended with fluid he looked ready to give birth to twins.

We first stopped by his room with Dr. P in the middle of a sonogram. The patient was quite calm; he’d been through this whole routine before and simply wanted the doctors to drain off the fluid and be on his way. Dr. P asked about his drinking history and a previous diagnosis of liver failure (cirrhosis), and then gestured me over to his far side.

“Place your hand on the side of his abdomen,” he told me.

Gingerly–I had the irrational feeling that if I pressed too hard he might pop like a water balloon–I placed my fingers on the side of his swollen stomach. Dr. P tapped lightly on the opposite side of his abdomen, and, like a taut drum, I could feel the vibrations moving through the fluid in waves.

The liver is a multifunction organ, and one of its many jobs in to synthesize the proteins that help keep fluid in your blood vessels. In the case of this patient, his liver was completely scarred over from years of alcohol abuse and could no longer perform this function. This caused the fluid that was supposed to carry blood cells to all regions of the body to leak out of the vessels and accumulate in his abdomen. This condition is known as ascites.

“Patients with ascites have a lot of the same complaints as pregnant women,” Dr. P told us. “All that fluid starts to push on their other organs, makes it difficult for the lungs to expand downward so it becomes hard to breathe. Plus they’re carrying around all that extra weight.”

Half an hour later we watched a couple of residents disappear behind the curtain. Dr. P encouraged us, me and another postbac who was shadowing that day, to watch.

We peered our heads around the curtain to see that one of the doctors already had a needle and catheter inserted into the lower left side of the patients abdomen. This was to avoid the jumble of organs that exist on the opposite side of the abdominal cavity. Something hadn’t been hooked up quite right, and much as you might imagine puncturing a water-filled balloon with a yarn needle, fluid was spilling out over the doctor’s gloved hands and onto the bed sheets. Quickly she scrambled to attach the hose to a vacuum pump that the other doctor had positioned on the floor near the patient’s head.

“The last time they did this they got four and a half liters,” the patient told us.

“How much do you think we’ll get this time?” asked the doctor holding the needle. “I’m going to guess four.”

“Oh I think it will be closer to five,” said the patient. “You’re going to want to get a few more jars,” he told the resident seated by his head.

As it turned out they needed four containers for all of the fluid, nearly seven liters (1.84 gallons) of a transparent, yellow-green liquid of a similar consistency as urine. And there was more where that came from. By the time they were finished, the patient’s bowling ball-sized stomach had shrunk down to nearly normal size. The skin over the remaining fluid rippled and sloshed like a water bed.

The patient argued with the doctors to keep going.

“We’re out of containers!” one of them protested. “You’ve filled them all up!”

When we returned to the main station, Dr. P explained the risks in draining too much fluid from a patient with ascites:

“The minute they drain that fluid, it starts to fill up again. And that fluid has to come from somewhere; it’s going to drain out of his blood vessels. So even though he has all of this fluid accumulating in his body, he’s going to be dehydrated. It’s like dying of thirst in the middle of the ocean.”

The patient didn’t seem terribly concerned about any of this. “I’ll see you again in five weeks,” he told the doctors as they removed the catheter.

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