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Every time you remember one of your patients, you are convinced that the fate of people passes through us, doctors. It was not me who developed the formula over the centuries: if you stop sympathizing and compassion with the sick, giving away a particle of your soul, you will only dryly see another case history or material for a medical experiment in front of you, you will not notice how you turn from a doctor into an artisan who is able to create only the necessary dishes in everyday life, but cannot make them ring and sing …

Another story of fate appeared to me in the form of a lean, lean colonel of military counterintelligence Denis Petrovich. He swam confidently into my office, along with him the fresh aroma of expensive perfume burst in, quickly mixing with the specific smell of disinfectants in the medical office and also quickly enveloping me. This feeling of freshness and purity, oddly enough, disposed us to a sincere and sincere conversation, from which I should have understood what task the visitor wanted to set for the doctor to solve in our location. Some discrepancy was evident between the strict and harsh army life in hot spots and a soft, docile character, a silky and melodious voice, smooth movements of refined and well-groomed musical hands with long fingers. A green satin shirt and a bright orange leather briefcase put a bold point in his image …

The task, it seemed to me, was simple at first glance. He was tormented by pains of moderate intensity in the epigastrium , along the esophagus, and something else, resembling a feeling of heartburn. I well remember the lecture of a professor from Germany, who explained the anatomical structure of the muscular layers of the esophagus to complaints and descriptions of the feeling of heartburn by patients. Therefore, I understood the difficulty our patient experienced in trying to express in military language what he felt when there was an acid reflux from the stomach into the esophagus. And of this I had no doubt, given the stress and food, which consisted only of cigarettes and coffee, sleepless nights and vigil over staff maps.

Of course, these were my conjectures, which help the endoscopist very well in searching for the causes of patient complaints in the vastness of the organs under study, as if you entered a dark room with a flashlight and looked for a clock, because someone heard tick. In our case with the officer, it seemed to me that I would find not just a watch, but chimes. In fact, it turned out that our patient had a pronounced inflammatory process at the junction of the esophagus to the stomach with the formation of many erosions and one deep ulcer, and the mucosa in this area, upon contact with the endoscope, responded with hemorrhages and abrasions. I was so fascinated by the discovery of these “chimes” that I quickly flew through the esophagus from the upper to the lower parts of it. There was no need to be in such a hurry! It is a typical mistake of endoscopists to use the esophagus as a conductor to the esophageal-gastric junction and the stomach, where various pathologies are most often encountered. However, I noted cheesy overlays on the mucosa of the esophagus at the very beginning when the endoscope was brought down. This is a classic sign of candidiasis, the growth of colonies of fungi of the genus Candida , often found with the abuse of antibiotics or a sharp decrease in immunity. Since the patient was primary, with a referral from a gastroenterologist, with a general blood test, which showed a slight decrease in the number of leukocytes (leukopenia) and an increase in lymphocytes (lymphocytosis), I didn’t want to think about a violation of immunity right away … We thought about going over antibiotics (with long treatment urologist), stress, poor nutrition, acid reflux and sent back to a gastroenterologist for further monitoring and treatment of complicated GERD ( gastroesophageal reflux disease).

There are many regularities in endoscopy. One of them – the higher the ulcer in relation to the head of a person, the longer and more difficult it heals. Accordingly, in the duodenal bulb, the defect usually epithelizes (i.e., is covered with new epithelium) in about 21 days, and in the upper sections of the stomach and esophagus, 1.5 months may not be enough. Therefore, my colleagues and I expected the same results from Denis Petrovich. But the standard treatment somehow did not work. There was no relief, which is usually expected as early as 3-4 days. Pain remained in the esophagus, as such there was no classic heartburn. The gastroenterologist thought. Several times he discussed the patient’s health with me. We decided to re-examine the condition of the mucous membranes at an extraordinary gastroscopy. We looked, nothing new – everything is the same as it was a month ago, without changes! As if our intelligence officer had not been treated.

During this time, we became very good friends with Denis Petrovich, we often called each other in the evenings and discussed the plan of our treatment and then moved on to friendly topics that were of interest to both of us. After all, your humble servant gave the Motherland 2 years of military service in the GRU special forces as a reconnaissance sniper. A burning and common heartfelt theme was the discussion of the spiritual path of each of us. We talked a lot about God’s providence, about the responsibility of man before man and before God, about the Gospel, about the holy fathers, remembering their labors… The second control gastroscopy was given on the eve of the New Year holidays and Christmas holidays. So we congratulated each other in advance, hugged like old old friends and decided to meet in the New Year and with renewed vigor to fight Denis Petrovich’s illness. As we were parting, Denis Petrovich whispered to me that on Christmas Eve he was leaving for two weeks at Optina Pustyn as a laborer to help the monastery physically and to pray… I got a lump in my throat, after all, only a friend can be trusted with such revelations, a brother in Christ. I thanked him for this trust and wished the Guardian Angel on the road, and again we parted warmly…

From the moment of the first appearance and until our last meeting, I remember his eyes. A little grayish, either with a blue tint, or with an emerald distance, a little clouded by some kind of veil – either by fog, or by a tear, and always sad and, as it were , apologizing for having dared to distract us from the good deeds to ourselves unworthy, with insignificant problems. Still, such eyes can keep some kind of secret that the interlocutor should be told, but either the time has not come, or there is not enough courage …

Upon my return, Denis Petrovich, to my tenderness, brought me various gifts from Optina . His condition has clearly not improved. And we diligently began, as planned, to break through the tightly held defenses of his illness, which we still do not understand. I don’t remember who suggested it, but our immunologist joined us, a real pro and a “monster” in his field, if you can talk like that about a fragile, pretty woman. She immediately took into circulation all past studies, passed the necessary tests, and found high titers of herpes viruses and Ebstein -Barr, which indicated an extreme decrease in immunity. Our immunologist suggested that the whole disease could be of viral etiology, and it would be good to try to take material from the esophagus into a special medium during gastroscopy. Well, the third gastroscopy in the last two months … But the desire to grasp at straws was great, and Denis Petrovich, fully trusting our council, agreed.

On the third gastroscopy, I wonderfully managed to take the material with a brush for biopsy . We placed everything in the appropriate container, and already sent it to the laboratory along with the waiting courier, when, leaving the esophagus in its upper third along the side wall, I notice a pale pink, slightly protruding formation similar to a covered volcano crater, which says: “Don’t bother me, otherwise I’ll give you like Vesuvius…” But this is not about us, not about endoscopists. We are a muscular people, we take a biopsy from everything that we do not like and do not understand. Of course, I remembered that it is extremely dangerous to take a biopsy in the esophagus, especially with an altered mucosa, which could threaten bleeding and perforation. After chewing on this information a little in my head, after a few seconds I commanded my assistant: “Biopsy, no needle!” This meant that it was necessary to use forceps with opening cups, between which there is no needle, which fixes the mucosa by pricking it, preventing the forceps from moving relative to the selected biopsy site. Now it’s useless to figure out whether the nurse made a mistake and gave the wrong instrument, or there were no forceps for gastroscopy without a needle, but I inserted the forceps into the gastroscope channel, as requested – without a needle, but for colonoscopy. I hasten to reassure the completely ignorant reader. Firstly, we always use only a single-use instrument, and it does not matter where it will be used for manipulations in the stomach, intestines or bronchi. It is sterile and disposable. The essence of the differences in the length, thickness and size of the cups. Colonoscopy forceps have slightly larger cups . A little, how much? At 1 mm. So it’s rubbish. Well, a trifle in accordance with our height, but in accordance with the thickness of the esophageal mucosa, this can already be critical.

I realized that the forceps were large when I pushed their tip out of the endoscope channel, when the folded polished head of the forceps appeared on the monitor of the video rack , and after the command “Open!” I saw huge open cups, moving away from each other in opposite directions, like the ejected stages of a space rocket. For endoscopists, the command “Open!” there is a reflexively formed command “Close!” It happens that a well-chosen focus for a biopsy does not shift due to the constant peristalsis of the organ or involuntary movements of the patient, these commands follow one after another with fractions of a second. It can be difficult to execute this verbal command accurately and quickly, which determines the level of professionalism of the endoscopist assistant.

Before I had time to command the opening, think about the size of the cups and the possibility of changing the forceps, as the brain, accustomed to the formed reflexes over the long endoscopic years, sent the command to close, and the speech apparatus said “Close!” Not even a second passed. The tongs with lightning speed and clearly where I wanted, squeezed the “crater of the volcano” with a death grip of steel. It seemed to me that the volcano groaned: “In vain the doctor …”

To separate the captured piece from the mucosa, it is necessary to apply a short strong tearing force perpendicularly and the piece will remain between the cups, and a defect will be born in the mucosa, which will momentarily fill with blood from the destroyed capillaries. Under standard biopsy conditions, capillary bleeding stops on its own within 2 minutes due to a normally functioning blood coagulation system in the body. In the esophagus, it will not be possible to deploy the endoscope perpendicular to the mucosa due to the limited space and its lumen. Therefore, as the tongs lay down, it’s nice …

But it didn’t work out nicely. I made a short tearing movement, but the effort turned out to be tangential , i.e. directed along the wall of the esophagus and mucosa. Within 1-2 seconds, I watched how, after the cups, a loose, almost unretained mucosal flap exfoliated, exposing the whitish layer of the inner muscular layer of the esophagus with the formation of a huge crater, from the upper edge of which a scarlet stream began to pulsate, peeling and inflating the opposite lower edge wounds.

In this situation, two remarkable statements come to mind. The first without authorship, which advises the patient: “Watch the doctor, if he is calm and does not fuss, then everything is under control. If not everything is under control, and the doctor is calm, he is probably deceiving you. We were calm, because in the arsenal we had many different ways to deal with this bleeding. The second statement of one of my St. Petersburg teachers, who said: “There is no need to be afraid of bleeding, it can always be stopped. It is necessary to be afraid of perforation (rupture) of the organ.

Having coped with the bleeding, we left our long-suffering colonel in the hospital under observation with intensive hemostatic therapy. The next day, according to all standards, it was necessary to do a control EGDS, although only with an examination of the esophagus, but the fourth in these two months, which of course caused some displeasure of our ward. Control has given us positive dynamics. Three days later, the patient was discharged to home rest.

A few days later came all his test results. After some doubts, dispelling them in clarifying ways, Denis Petrovich was given a verdict – acquired immune deficiency syndrome – AIDS ….

We saw him several times after this verdict and talked. I still warmly hugged him and shook his hand, trying with all my appearance to make it clear that this is just a disease, it must be fought, for all the will of God, and God’s providence …

Denis Petrovich stopped visiting our clinic, disappeared, and I didn’t see him again, call and ask how his health is, I still lack the spirit …

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