70-year-old Mrs. Edwards rolled into the ICU at 0100, pale, sweaty and tachycardic with a blood pressure of 80/49.  The night shift nurse, Rebecca, and a crowd of others deftly hooked up the heart monitor, intravenous lines, and other devices, checked her urine output, and peeked at her dressing, which was oozing just a bit. "I'm giving her another liter of LR," said Rebecca, wondering why this lady was transported in this condition.  Mrs. Edwards' pallor and sweaty, cool skin were enough to tell her this could be a bad night. "What was her intake and output?"  Rebecca was thinking that blood loss had driven Mrs. Edwards' circulation to the crisis point, and she wanted to know what to give her: more fluids, blood?

Mrs. Edwards' last blood gas showed metabolic acidosis from lack of oxygen to her vital tissues. The longer acidosis persists, the worse the outcome for the patient. This grim picture began to make more sense when the surgeon told the story of Mrs. Edwards' lengthy operation.

The chief surgeon, Christine, recalled aloud how she searched Mrs. Edwards' abdomen for the source of the smelly pus-blood-plasma mixture. After examining the usual suspects, the stomach, appendix and bowel, the surgical team moved on to the left upper abdominal quadrant, and found Mrs. Edwards' spleen encased in omentum, an apron of fat that envelops trouble spots, making a built-in physiologic bandage when something goes wrong in the abdomen. 

Omentum wrapped around an organ signals trouble inside. Most people don't even know they have omentum (in fact, humans have two omenta: greater and lesser) although this under-appreciated structure could save their lives.  Because despite what Dr. Oz said on Oprah, your omentum is not trying to kill you.  (And craving meat is not a sign of anger, either, if you ask me.) Mrs. Edwards, I think, would vouch for the good intentions of her omentum.

Christine recounted how cautiously incising the omentum brought forth a flood of pus-filled fluid.  Then Mrs. Edwards' spleen was removed, the surgeons flushed out the abdominal cavity, placed a drain to take away the residual nastiness, and closed Mrs. Edwards back up.

Unfortunately, removing the offending organ was not a cure. The infection had made itself a comfortable home in Mrs. Edwards' warm, moist abdomen, and it wasn't going away without a fight.  Although antibiotics are a first line against sepsis, once septic shock sets in, the game changes.  Antibiotics must be given early in the development of sepsis to be very helpful, and Mrs. Edwards had shown up in the Emergency Department a little too late for that, unfortunately.

So now, this obese older woman, minus a spleen and some omentum, was in dire need of intensive caring.  On a ventilator with a tube in her throat and sedated, she couldn't speak, but she made her need for pain medication clear.  Rebecca worked to stabilize her vital signs, treat her pain, and monitor for complications of shock, like acute renal failure and delirium.  

When I arrived at 7:15 a.m., Rebecca had Mrs. Edwards nicely buttoned down. Fluids were running, pain was controlled, her family was informed, and she was alert enough to communicate, but sedated enough to be comfortable and forget.  The forgetting is important. An ICU is loud, well-lit, and a place where uncomfortable, if not painful, things happen.  For a long time, ICU practitioners gave drugs to induce forgetting with abandon. Now we know that moderation is better, because forgetting can prompt the brain to create memories that are scarier than the real ones. A daily sedation vacation even helps prevent pneumonia.

This story ends well. I checked up on Mrs. Edwards a few days later to find that she had left intensive care and was progressing toward discharge.  I wondered if she knew that she had her omentum to thank, at least in part.