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Resurrection My Nine Second Comings With heartfelt thanks to… Carola, meine Frau, who with her first assessment and immediate declaration of emergency, undoubtedly saved my life, and for her daily presence and love before, during, and after my crisis. My daughter Radha, who called me regularly to stay informed of my status, to keep me in good spirits, to declare “I don’t want to lose you”, and to check my “out of Australia” medical insurance status. The emergency ambulance team who revived me and delivered me safely to Dinkelsbühl (DE) hospital. The most excellent doctors and Intensive Care team of Dinkelsbühl hospital who took such great care of me. It was a pleasure to be in a very personal village hospital. Hello Helmut et al. I’m sorry I don’t remember all of your names. Agata and Dimar, both Russian friends of Carola, living in Rostock DE; Nadezhda Koroleva and Vadim Korolev from Russia, who remotely diagnosed me and made controls to treat the symptoms of my pain, and guided me through stepping out of the foreign events leading to the situation. They saw things in me which I did not. Two new and wonderful friends, Jan and Helma, who invited me into their home without knowing me before-hand and cared for me for several days after my discharge, then drove me 333km to Frankfurt airport. Our TP Thai friends, all of whom made dedications for me and my health in the Thai Buddhist traditions. All you wonderful souls - Thailand Project participants from past and future, too many to name here - who heard about my situation and sent me your best wishes, and who made individual and group controls to restore my health. I felt your work. Grigori Grabovoi, who made this Creator Knowledge available, with the express desire that those who master it will pass it on to all humans, for the benefit of all. I know they give you a difficult time Grigori, I know you will prevail, I send you my best wishes at all times. With love… Maxwell Contents Experiences in other levels… ........................................................................................4 Europe, August/September 2012 .....................................................................................................4 Wildenstein, Baden-Wurttemberg, Deutschland .......................................................................................4 August 23, 2012 ...................................................................................................................................................4 August 29, 2012 ...................................................................................................................................................4 NDE 1, Uh Oh ..................................................................................................................................................................4 NDE 2 & 3, A Rough Ride ................................................................................................................................................5 NDE 4, Dinkelsbühl. Alles In Ordnung? Not Really.......................................................................................................5 August 30, 2012 ...................................................................................................................................................5 August 31, 2012 ...................................................................................................................................................5 The shit hits the fan… ..........................................................................................................................................6 NDE 5, Body Reconstruction ............................................................................................................................................6 The operation .......................................................................................................................................................6 NDE 6 ...............................................................................................................................................................................6 Three hours later ..................................................................................................................................................6 NDE 7 ...............................................................................................................................................................................6 September 2-11, 2012 ..........................................................................................................................................7 Leaving this existence… ......................................................................................................................................7 NDE 8, Really Gone, Into The Future I Believe ...............................................................................................................7 NDE 9, A Combination .....................................................................................................................................................7 The Grey Planet.....................................................................................................................................................................................7 The Grey Planet, Again .........................................................................................................................................................................7 The Many Coloured Spheres .................................................................................................................................................................7 The ZERO..............................................................................................................................................................................................8 It’s over, it’s over, it’s o-o-o-over, it’s over!.........................................................................................................8 September 11-13 ..................................................................................................................................................8 Wildenstein, September 13-16 ..................................................................................................................8 Thailand ....................................................................................................................................................9 September 17-19 ..................................................................................................................................................9 Nadezhda And Wadim Koroljov ........................................................................................................................................9 September 20........................................................................................................................................................9 Creator Knowledge ........................................................................................................................10 My take on this…...............................................................................................................................................10 This Knowledge is a must-have for everyone....................................................................................................10 The hospital report… .....................................................................................................................11 Deutsch… ..........................................................................................................................................................11 Diagnose: ........................................................................................................................................................................11 Therapie:.........................................................................................................................................................................11 Behandlung Und Verlauf:................................................................................................................................................11 Therapievorschlag: .........................................................................................................................................................12 Letzte Medikation: ..........................................................................................................................................................12 English… ...........................................................................................................................................................13 Diagnosis: .......................................................................................................................................................................13 Therapy: ..........................................................................................................................................................................13 Treatment And Course: ...................................................................................................................................................13 Recommended Treatment: ...............................................................................................................................................14 Last Medication: .............................................................................................................................................................14 Leaving this 3D existence… And returning… ❆ ! to contents Experiences In Other Levels… Europe, August/September 2012 Wildenstein, Baden-Wurttemberg, Deutschland After almost a month in Germany and Switzerland any many kilometres by train and car visiting old and new friends, Max and Carola finally make it to Wildenstein to meet with Carola’s Schwäbisch friends Jan and Helma, to catch up on what’s happening in each others’ lives, and generally to rest. Wildenstein is so quiet and relaxed I declare that I will stay here. We take a room in a small Gasthaus. The pains in the ribs and spine had already begun in Thailand; I have a high tolerance to pain so I ignored the warning signals. This technique has worked flawlessly throughout my life, so why should I treat this differently? August 23, 2012 The pain continues; Carola insists; I relent. She takes me to Dinkelsbühl hospital for a checkup. The X-ray shows 2 vertebrae out of place and 2 distorted ribs. The doctor prescribes pain killers. Returning to the Gasthaus, I rest to escape the pain and to reduce the pain killer intake. Medication is not my thing. My situation improves and I become lively again, except for 2 or 3 pain attacks each night. Sleep is uncomfortable. I know something is NOT OK, but I think it’s related to the spine and ribs, and I will have this all rectified in Thailand. I wasn’t aware of the damage I was doing through selfneglect. Life continues, until… August 29, 2012 NDE1 1, Uh Oh I collapse in the bathroom with the knowledge that I am dying - it’s not so bad after all - I do not lose consciousness nor leave my body, but lose all my strength… I lie on the floor in a pool of vomited blood. I have children, grandchildren, and Carola. I decide to not die - I stay in my body. Also my father is approaching death at this stage in Australia, and I don’t want him to have a shock which might tip him “over the edge”. (I did not see him nor speak with him again, he died a few weeks later while I was recovering). I struggle to my feet to take a shower. I don’t want to be seen like this. I can barely organise a flow of water. Carola arrives, sees, and calls the ambulance. It’s hopeless - I sit on the shower floor and do my best with Carola’s help, to clean myself. Some strangers help me to bed. The same doctor from Dinkelsbühl hospital attends. His greeting is a warm “Ah, Maxwell Stirling.” I reply, “Igor.” Already, he seems to be an old friend. “A drowning man will clutch at a snake” ☺. Carola & I both feel very comfortable with him and know all will be well handled. We assume 1 NDE: Near Death Experience © Maxwell Stirling, 10/2012! to contents! 4 Leaving this 3D existence… And returning… ❆ ! to contents he’s originally Russian. Igor begins to work on me - the emergency hand-held saline drip bag. I feel a little more composed now. The emergency team carries me down two flights of stairs in an inflatable flexible stretcher. It’s the only method they can use, there is no elevator. It’s a bumpy ride, and I feel shock coming on. I no longer care about anything. NDE 2 & 3, A Rough Ride The roads in and around the very old village of Dinkelsbühl are built of cobblestone, I assume by Roman invaders from Julius Caesar’s days, and are very rough. It’s a slow drive. I “die” (OBE) 2 twice during the ride to hospital - they stop the ambulance to revive me. I’m aware of taking a different journey each time, into other realms, and again say “No! I do NOT die, I go back.” Both times I regain consciousness to find the Ambulance team acting extremely concerned and doing their best to revive me. I need to put them at ease. “Cold… Shock…” I say, and I can still manage a smile. They smile. NDE 4, Dinkelsbühl. Alles In Ordnung? Not Really. I “die” again on arrival at the hospital, during the unloading. I don’t recall the journey through the corridors. Again I decide to go back into my body. I sleep, wake, sleep, wake, oh blessed sleep and rest, so nice. I hear talk of an endoscopy and sleep again. They allow Carola in the examination room with me, an exception to their rules, because they need to be sure of good translation for information exchange. At this stage all of my limited German is gone. I only recall waking while the doctor inserts the camera-on-a-probe and quickly fall asleep again before they finish. I see about 2 seconds worth of my internals on a display. They locate but cannot treat the source of the blood release, it is out of the reach of the endoscope. The doctor decides to wait, as after the endoscopy and blood pumping, it appears that I am recovering, and that the bleeding has stopped. So now I’m in a bed in Intensive Care, hooked to blood and nutrient infusions. They say I lost more than half of my blood supply, and was three hours maximum from physical termination. August 30, 2012 Recovering and improving. Carola is busy with many things, she has a full plate, and now this on top. She spends about half the day with me and half on her work. The general consensus among the doctors is that my crisis is over, but they want to do another endoscopy later to be sure all is well. August 31, 2012 Carola has a dilemma - she flies to Thailand soon - and decides to postpone. I talk with her about this - she has organised a seminar beginning on September 10, with 34 EU & AU participants, 2 Russian presenters, 2 translators, and a Thai team of around 18. A nightmare to re-organise. I say she must return, I will follow as soon as I’m able. She’s not happy and wants to cancel the seminar. I insist several times and she finally accepts; there is much preparation to finalise before the seminar begins. 2 OBE: Out Of Body Experience © Maxwell Stirling, 10/2012! to contents! 5 Leaving this 3D existence… And returning… ❆ ! to contents The shit hits the fan… The doctors want to do another endoscopy, they are uncomfortable about not treating the source of the internal bleeding, so they prepare me for another throat-scope, and wheel my bed to the examination room. NDE 5, Body Reconstruction While waiting in bed in the corridor for a examination room vacancy, I lose 3D consciousness again for a short time. Visiting another realm, I again state very clearly to myself “No!”. I know I’m in trouble, that I must go to my Point of Reconstruction. The thought alone takes me there where I immediately instruct my eternal body cells “Reconstruct my body!”. They do. I am back in my body and wake to find everyone in a panic, so again I have to demonstrate that I am still here - but I am so weak… The bleeding had re-commenced. The operation During the endoscopy the doctor controls the bleeding source and declares an operation is necessary. I am given no choice now - well not exactly true - they give me the choice of “operate or ………” . The damage is severe, life threatening. NDE 6 I agree to the operation - actually Carola agrees, I gave her the authority. I am consciously gone again, having yet another “other realm” experience. No, I decide to return again. Awakening, I manage to say to Carola, “We see each other again in Chiang Mai.” She has different aspirations, “No,” she says, “after the operation.” The surgeons have me now, I am under anaesthetic, she must leave the operating theatre and wait. I remember nothing of the operation, narcotics work well. ☺ Three hours later The operation is successful, they reseal me and stitch the wound. At some stage I regain enough awareness to experience my surroundings, in what has become my room by now (possession is a strange beast). Everything is vague, I slip in and out of sleep for short periods. Carola watches, whispering to me all the while. It really is intensive care, doctors and nurses continually hovering, adjusting the life support connections and all the drip medications. After receiving so much foreign blood I wonder who I am now. It’s funny what you can think of when you’re strange. Happily, I have no idea I’m on a breathing machine with my hands fastened to the bedsides lest I try to remove the breathing tube. Carola keeps watch, is saddened by my imprisonment, and waits. I don’t see her. NDE 7 I’m told I was put into artificial coma for 3 days, but I shortened it to 1.5 days, by, and I don’t know how many times, consciously continuing to return from the other realms I was visiting. I recall on one occasion using the Periodic Table of The Elements to rebalance my body chemistry after so much artificial medication. Even when in coma, soul, spirit and consciousness are fully alert, accurate, specific, and prepared to recreate each body cell to its design state. Spirit waits only for our command. © Maxwell Stirling, 10/2012! to contents! 6 Leaving this 3D existence… And returning… ❆ ! to contents Carola waits… and waits… and begins to reorganise my flight. September 2-11, 2012 Out of coma. No breathing machine, no throat tubes. I remember nothing of it. It’s crunch time, now Carola must decide. I help her by remaining unconscious and nonparticipatory; the doctors say I am fine now and will recover. She says her goodbyes; the last she sees of me I am hiding behind a mass of tubes. She feels more comfortable with the doctors’ assurances, but is not happy to leave. She says “You were right, we see each other in Chiang Mai”. I don’t hear. I do not see her again in Germany. She held it together so well. I’m happy she wasn’t here for what followed. It would be difficult to explain it all while under drugs. Some things are best left unsaid. (She knows now of course). Carola leaves, unhappily. “Love won’t leave you alone” Freddie Mercury Leaving this existence… Now the experiences really kick in, triggered by hallucinations on the wall in front of me. I remain fully conscious while out of my body. I lose track of time, I have no memory of the dates. NDE 8, Really Gone, Into The Future I Believe I view the universe, noticing certain parts (stars, solar systems, galaxies) which stand out and are more attractive than the rest. I take these parts and place them in my body in certain key points unknown to me before and now. I simply know what to do automatically. I have become bold now, I know this is good for me, the universe is my friend and my creation. I scan my body and take those parts which look out of order, and place them in the attractive areas of the universe. This all feels so right. I am free. I see things and places I cannot describe, they have no Earth language equivalent, purely images in motion, different pulses and intensities of light, natural non-Earthly substances, geometric and non-geometric shapes (blobs?), things I have not seen before. Some I see for a fleeting second, others a little longer, it all passes before me, flash flash flash, like an epilepsy episode. It’s beautiful to behold. I cannot say for how long this continues. It is pure recreation, plain and simple. Without making any decisions, I’m back for more sleep. NDE 9, A Combination The Grey Planet The wall shimmers, is entirely grey, and transforms into a lifeless planet. The surface is grey, organic dirt, pock marked, no vegetation. Imagine you are looking at the twilight zone of the moon. It is NOT the moon. This planet is not in this plane, it has it’s own existence. Later, in Thailand, Nadezhda had something to say about this planet. I’m viewing from inside a “transport ship” through a porthole, as a passenger would from the aisle seat in an aeroplane. I see the planet has a narrow ring and realise I’m viewing it from the “south”. It’s immense, I see nothing but planet. I’m the sole passenger. On returning to my body and some reflection on this experience, I wonder if I’m the pilot or the commander. The Grey Planet, Again It’s the same grey planet, this time I have more clarity. I’m in the transport ship, but it’s a different experience. This time my view is unobstructed by a porthole, I see the through the ship’s hull. My vision is 360°, inside and outside, an empowering feeling. Wherever I look I know I can go there. I am unwilling to go further, unwilling to stay, I decide to return to my body, and I’m back immediately. The Grey Planet is but a memory. Sleep… The Many Coloured Spheres It’s very clear to me - I’m leaving this existence level. © Maxwell Stirling, 10/2012! to contents! 7 Leaving this 3D existence… And returning… ❆ ! to contents In front of me are many spheres of different sizes and colours; red, blue, violet, yellow, green, orange, some contain multi coloured bands - I notice there are no browns, greys, or blacks. I walk/float/teleport through and between them, always forwards. I’m not sure of the motion, it seems as if I simply look at my next destination and I’m there. I know what is happening, that I’ve left my body big time - these are my own creations to bring me back into this dimension. I caress these spheres with my vision and I’m filled with a beautiful feeling of love and complete relaxation. I decide to go back, and I am back - in an instant. Sleep… The ZERO Leaving my body again. In front of me I see the bright outline of a ZERO, like a smoke ring in motion, slightly larger than I am, and realise I need it desperately. This OBE is serious. I know the meaning of the ZERO - transformation and changing dimensions, a 2-way portal. I ask myself “Is this it? Is my Earth life finished? Am I being taken away?”. Then I remember that I create everything, even the ZERO, so it is my tool and it will do what I want. I decide to go back. The ZERO is hollow. Realising I am now on the “wrong” side of the ZERO I step through it, and I’m immediately back in my body. Sleep… It’s over, it’s over, it’s o-o-o-over, it’s over! There are no more “out of body” experiences after this, I know I’ve survived. I continue to recover daily. My spirits rise, my wound improves. I regain physical abilities. With help I walk the hospital floors to regain lung and muscle strength, and co-ordination. Every day, I am impressed by and grateful for the close personal attitude and actions of the individual staff with whom I have contact. Care is definitely their motto. If you absolutely must have an emergency - not recommended - Dinkelsbühl is the place to do it. Jan enters the picture and visits me daily. He is such a lovely, life-intelligent man and we have very interesting “not run of the mill” conversations. He speaks excellent English. We share our life experiences. All is good in Dinkelsbühl. September 11-13 I am now out of Intensive Care, in a recovery ward, alone thankfully. Jan continues his daily visits. He offers to smuggle nice food in for me. I decline, deciding to trust the hospital regimen. This is very unusual for me, I like to please myself. The doctors who assess me daily are impressed by my condition. The physiotherapists teach me correct breathing again. I did not forget how, it was only a matter of lung strength. Wildenstein, September 13-16 September 13th, the stitches are removed, and they release me. Jan checks me out of hospital and brings me to his home where Helma greets me and takes me to my room. I meet their two sons, Amadeus and Arian. They take excellent care of me for 3 more days although they both have very busy lives. I overdo it with the Laugenbrezel, I cannot resist. It is a beautiful feeling to have a home life again. Jan drives me to Frankfurt airport on September 16. 333 kilometres. Alone again and physically very uncomfortable, I know I’ll make it safely. The 2 flights to Chiang Mai are very uncomfortable. © Maxwell Stirling, 10/2012! to contents! 8 Leaving this 3D existence… And returning… ❆ ! to contents Thailand September 17-19 I arrive in Thailand in a weak condition on September 17 - Carola greets me in Chiang Mai airport - and go straight to bed when home and sleep until next afternoon. Next evening (18th) I go to dinner with the seminar participants, most of whom I know from various prior seminars. Their greetings are amazing, they had been making so many controls for me during their seminar. I make a speech, welcoming all, especially Nadezhda and Vadim. Cheekily, (it was the eighth seminar day), as it’s my wish, I declare the seminar Open. Much laughter and applause. Tears flow on both sides. Nadezhda And Vadim Koroljov Here I meet Nadezhda and Vadim for the first time. They are both direct students of Grigori Grabovoi, extremely clairvoyant, healers, and present the Creator Knowledge in their own way in Russia and Germany. This is their first time outside of Europe, they love it here, they love presenting the seminar and they love the participants’ advanced understanding. They say we are all special. Particularly Carola for transporting this Creator Knowledge so clearly to so many. We are familiar with each other due to the remote healing they performed on me on August 5th and 6th while Carola and I were in Rostock, and we spend some time re-establishing our connections. They had viewed then that I have 2 damaged ribs and 2 vertebra out of alignment, later confirmed by X-ray, and had told me that I must seriously step out of the events leading to the damage. I met Agata for the second time and Dimar for the first in Rostock. We have a “chat” about my condition; they both make Creator Knowledge controls, adjustments to my psyche and thinking processes, and tune my body, all to ensure I make full and swift recovery. The chat resembles a gentle inquisition. ☺ The evening of the 19th I go to the participants’ farewell party, and stay too long, I’m very tired and both stomach and wound begin to hurt. Wrong food and drink. I must leave. September 20 Nadezhda and Vadim visit, “the healing is not finished,” they explain, “now we get serious.” This time it’s definitely an inquisition. They want all my information. Anna and Helena translate. Agata, Brian and Marion listen in. In brief, I tell them everything I’ve told above. They are both very interested in the Grey Planet, saying that I’m the last representative from this one, destroyed during the Star Wars. So, I think, “Conceptually, the movie was real”. (This also coincides with Valentina’s - another direct student of Grabovoi and clairvoyant healer - previous assessment that I must resurrect my entire civilisation - I’m the last). They say there is no help for me on Earth from my civilisation, I’m the last, and that I should not visit the planet again, not even think about it. But of course I do. How can I not? I’m still a rebel. You cannot forget an experience, it’s stored in memory, even if out of 3D. They are worried that if I go there again (into the past) those existing then can rob me of energy, so that I’m weak and damaged when I return to the present. You may be thinking this is strange, but I have been in the past and the future. I know that all time zones - past, present and future - co-exist now, in the moment. We live outside of time. They work on me continuously during the conversation for over an hour until I feel fine. The breakthrough is due to Vadim asking “Why is this taking so long, it should be easy”. I have a © Maxwell Stirling, 10/2012! to contents! 9 Leaving this 3D existence… And returning… ❆ ! to contents realisation and say “Tutti è facile per me! (everything is easy for me)”, and it is done. I feel fine and my strength returns. We are all relieved, say our goodbyes, and they leave, warning me to rest well for a good two months. I have not seen them again yet - I will in the future, I know it. ☺ Creator Knowledge My take on this… I say now that due to this Creator Knowledge I knew what was happening every time I had an Out-of-Body or Near-Death Experience. This enabled me to decide during the process; “No I’m going back”. Sorry, I did not reach the “Pearly Gates”, nor heaven, nor meet any escorting angels, nor face any other concepts. I was alone the whole time. Yes totally alone. Just me. I made all decisions and direction changes without influence from “others”. I call this true Control. Others have said there is nothing out there during the OBE. Believe me, they are totally incorrect. Their perception must be severely limited to the extent that they do not believe in themselves, perhaps thinking there is only fate, therefore becoming its victim. There is a vast Universe, within and without. You may call it The All. I was also able to heal myself efficiently and quickly. It’s all in the Consciousness. The doctors were amazed that they could release me for a long-haul flight so soon after the operation. They had in mind 3 to 4 weeks in a recovery home. “Meanwhile, the patient is again symptom-free and so far mobilised, such that he can be released on this day of our inpatient treatment. “Inzwischen ist der Patient wieder insoweit beschwerdefrei und mobilisiert, so dass er am heutigen Tage aus unsere stationären Behandlung entlassen werden kann.” Because of much practice and familiarity, the methods came in image form without words, and sometimes I had only to think of a method and it was done. Think about this. This is why we’re pedantic about the need for frequent practice. You never know when it will re-pay you. This Knowledge is a must-have for everyone The life force is very strong in all of us. You’re not so sure? Just try holding your breath - how long you can hold it? No matter how long, you cannot prevent the next breath from coming. And this is only the body I’m speaking of. Think about spirit, soul, consciousness. How strong they must be! Together, they create and constantly re-create (maintain) our body, and they will not let it go easily. Only if it is beyond repair, or no longer serves the purpose of development will they leave it behind. Some people I know (who have this knowledge) are so brash they are saying I opened the doors of Resurrection on this planet, which will make it easier for all humans in the future to do the same. Hmmmm… I’m not so brash, I know I’m not the first to do this. I recommend that no-one duplicates my experience. Maxwell © Maxwell Stirling, 10/2012! to contents! 10 Leaving this existence… And returning… ❆ The hospital report… Deutsch…! (English) Stirling Maxwell Sehr geehrter Herr Kollege Ihr Patient stand vom 31.08.2012 bis 13.09.2012 in unserer stationären Behandlung. Diagnose: Großes, blutendes Ulcus im bereich des Bulbus duodeni bei Z.n. Einnahme von nichtsteroidalen Antirheumatika. Z.n. Blutungsanämie mit Transfusion von insgesamt 12 Erythrozytenkonzentraten und 2 FFP's Z.n. postoperativer basaler Pneumonie mit Pleuraergüssen beidseits Therapie: Notfallmäßige Laparotomie mit Duodenotomie und Ulcus umstechung am 31.08.12 in Intubations vollnarkose Postoperativ intensivcomplex medizinische Behandlung, u.a. mit erneuter Bluttransfusion und Helicobacter-pylori-Eradikationstherapie Behandlung Und Verlauf: Der o.g Patient war in den späten Mittagstunden des 29.08.12 mit der Symptomatik einer kreislauf und Hämoglobinwirksamen oberen gastrointestinalen Blutung vom Notarzt auf unsere hiesiger internistische Abteilung eingewiesen worden. Anamnestisch vorausgegangen war die Einnahme eines nichtsteroidalen Antirheumatikums (Ibuprofen) wegen Rückenschmerzen seit dem 23.08.12. Endoskopisch konnte ein großes Ulcus im Bereich des Bulbus duodeni mit stattgehabte Blutung diagnostiziert werden. Ein Gefäßstumpf im Bereich der Bulbus-spitze war endoskopisch nur schwer zugängig, wurde dennoch mit Suprarenin unterspritzt. Begleitend war die Transfusion von insgesamt erforderlich 7 Erythrozyten konzentraten und 2 FFP's unter intensivmedizinischer Betreuung des Patienten erforderlich geworden. Bezüglich der weiteren internistischen Vorgeschichte verweisen wir auf den Verlegungsbrief unserer internistischen Kollegen. In den Morgenstunden des 31.08.12 kam es dann erneut zu einer Blutung aus besagtem Ulcus duodeni, so das jetzt die Indikation zur operativchirurgischen Sanierung gestellt wurde. Unmittelbar nach Übernahme des Patienten auf unsere hiesige allgemeinechirurgische Abteilung Führten wir die notfallmäßige Laparotomie durch. Bei der Palpatorischen Exploration des Duodenums war an der Hinterwand des Bulbus eine großen Ulcus Nische zu tasten. Nach Duodenotomie, bestätige sich der Befund eines großen und tiefreichenden Ulcus mit derbem Ulcus grund, und fraglich kleinem gefäßstumpf im distalen Bereich, wobei zum Operationszeitpunkt eine aktuelle Blutung weder aus dem Ulcus grund noch dem erheblich aufgeworfenen zirkulären Ulcus rand bestand. Therapeutisch fürhten wir die mehrfache Ulcus umstechung durch. Die Duodenotomie wurde zweireihig verschlossen und mit Fibrinkleber gesichert. Der Patient konnte unmittelbar postoperativ geplant, und problemlos extubiert werden, und wurde sodann bis einschl. zum 09.09.12 auf unserer hiesigen interdisziplinären Intensivstation betreut. Postoperativ war die Transfusion von nochmals 5 Erythrozyten konzentraten notwendig, um den Hämoglobinwert auf gewünschtem Niveau zu stabilisieren. Eine HelicobacterEradikationstherapie erfolgte ebenso wie eine hochdosierte medikamentöse Thromboembolie-prophylaxe mit einem 1 x tgl. S.c. zu applizierenden niedermolekularen Heparin. Am 4. postoperativen Tage war der Patient plötzlich schweißig, begleitet von einen Troponin-T Anstieg. Die weiterführende Diagnostik ergab jedoch weder Hinweise auf eine Lungenembolie noch einem Myokardinfarkt. Radiologische zeigte sich jedoch eine basale Pneumonie beidseits mit Pleuraergüssen. Therapeutisch kam hier ein intensives Atemtraining unter krankengymnastischer Anleitung zum Einsatz, begleitet von der Medikation mit einem Sekretolytikum. Die postoperativ Mobilisation wurde von dem Patienten gut toleriert. Postoperativ führten wir zunächst eine vollständige parenterale Ernährung über einem zentralvenösen Zugang durch. Der Stuhlgang kam nach abführenden Maßnahmen regelrecht in Gang. Der nachfolgende Kostaufbau wurde ebenfalls gut vertragen. Die Analgesie erfolgte zunächst intravenös und später peroral. Die Wundheilung verlief bislang reizlos. sämtliche Ableitungen sowie auch die Hautklammern konnten termingerecht entfernt werden. 11 Leaving this existence… And returning… ❆ A m 1 0 . p o s t o p e r a t i v e n Ta g e f i e l laborchemisch ein erneuter leichter Ansteig der Leukozytenzahl und des CRP-Wertes auf, j e d o c h o h n e Te m p e r a t u r e r h ö h u n g . Nachfolgend kam es alsbald wieder zu einer beginnenden Normalisierung der laborchemischen Entzündungsparameter. Eine weiterführende Diagnostik in Form einer Röntgenkontrollaufnahme des Thorax und auch einer Sonographie der Pleura beidseits wurde von dem Patienten abgelehnt. N a c h a b g e s c h l o s s e n e r H e l i c o b a c t e rEradikationstherapie haben wir die hochdosiert Medikation mit dem Protonenpumpeninhibitor zunächst unverändert fortgesetzt. Inzwischen ist der Patient wieder insoweit beschwerdefrei und mobilisiert, so dass er am heutigen Tage aus unsere stationären Behandlung entlassen werden kann. Letzte Medikation: Pantaprozol 40 1-0-1 Acetylcystein Brause 1-0-0 Dalteparin Natrium 5000 iE 1x tgl. s.c. Metamizol bei Bedarf bis zu 4 x 40 Tropfen Natrium picosulfat bei Bedarf bis zu 20 Tropfen Mit besten Dank für die Einweisung und freundlichen kollegialen Grüßen Dinkelsbühl,, 13.09.2012 Therapievorschlag: Wir bitten um Fortführung der regelmäßigen Wundkontrollen. Ansonsten Fortsetzung des Kostaufbaus. Momentan nimmt der Patient leichte Kost zu sich. Auf einem Regelmäßigen Stuhlgang sollte unbedingt geachtet werden, ggf. Einsatz milder Laxanzien, und zwar vorzugsweise von Natrium Pico-Sulfat. Die Medikation mit der Protonenpumpeninhibitor sollte zunächst noch fortgesetzt, später in der Dosis reduziert werden. Bedarfsweise Fortführung der analgetischen Medikation, wobei ein konventionelles nichtsteroidales Antirheumatikum in Anbetracht des o.g. Krankenheitsverlaufes streng kontraindiziert ist; auch ansonsten sollten sämtliche potenziell ulcerogene Substanzen unbedingt vermieden werden. Fortsetzung der Mobilisation sowie zunächst noch der sekretolytischen Medikation. Die medikamentöse Thromboembolieprophylaxe sollte für noch eine Woche fortgesetzt werden, vorzugsweise mit einem 1 x tgl. s.c. zu applizierenden niedermolekularen Heparin unter gelegentlicher Kontrolle der Thrombozytenzahl. © Maxwell Stirling, 10/2012! 12 Leaving this existence… And returning… ❆ English…! (Deutsch) Stirling Maxwell Dear Colleague Your patient was from 31.08.2012 to 13.09.2012 in our residential treatment. Diagnosis: Large, bleeding ulcer in the area of the duodenal bulb with Zn Taking NSAIDs. Z.n. Blood loss anaemia with transfusion of a total of 12 red blood cell concentrates and 2 FFP's Z.n. postoperative basal pneumonia with pleural effusions on both sides Therapy: Moderate emergency laparotomy with duodenotomy and ulcer suturing on 31/08/12 in full anaesthesia intubation Postoperative intensive complex medical treatment, etc. with renewed blood transfusion and Helicobacter pylori eradication therapy Treatment And Course: The above patient was admitted in the late afternoon hours of 29.08.12 with symptoms of circulatory and haemoglobin active upper gastrointestinal bleeding by local emergency on our internal department. Preceded by a history of taking a non-steroidal antiinflammatory drug (Ibuprofen) because of back pain since 23/08/12. Endoscopy was a large ulcer in the duodenal bulb diagnosed with previous history of bleeding. A visible vessel in the bulb tip was difficult to endoscopically access, yet was then injected with epinephrine. Accompanying the transfusion of red cell concentrates in total 7 required, and 2 FFP's was necessary under intensive medical care of the patient. Regarding the other internist history we refer to the relocation of our internist colleagues letter. In the morning hours of 31/08/12, there was again a bleeding from the said duodenal ulcer so this has now made the indication for surgical reconstruction surgery. Immediately after acquisition of the patient at our local general surgery department, we performed the emergency laparotomy regular. During the palpatory exploration of the duodenum a large ulcer niche was palpable on the posterior wall of the bulb. After the duodenotomy, the findings confirm a large and profound gastric ulcer with rough ground and a questionable small vessel stump © Maxwell Stirling, 10/2012! in the distal region, which at the time of surgery was not an actual bleeding from the ulcer due to the still considerably raised circular ulcer edge. Therapeutically we controlled the multiple ulcer by suturing. The duodenotomy was sealed double row and secured with fibrin glue. The patient was scheduled immediately after surgery, and extubated without difficulty, and was then supported for up until 09/09/12 in our local multidisciplinary intensive care unit. Postoperative transfusion of again 5 erythrocytes concentrates was necessary to stabilise the haemoglobin level in the desired level. Helicobacter eradication therapy was like a high-dose drug thromboembolism prophylaxis with 1 x daily Sc to be administered low molecular weight heparin. On the 4th day after surgery, the patient was suddenly sweaty, accompanied by a rise in troponin-T. Further diagnostic however showed no evidence of pulmonary embolism or myocardial infarction. Radiology showed basal pneumonia with bilateral pleural effusions. Therapeutically here an intensive respiratory training came under guidance of a physiotherapist to use, accompanied by the medication with a secretolytic. The postoperative mobilisation was well tolerated by the patient. Postoperatively, we performed first a total parenteral nutrition through a central venous line. The bowels were proper after laxative regimen was underway. The subsequent food intake was also well tolerated. The analgesia was initially intravenous and then oral. Wound healing has progressed without irritation. all derivatives as well as the skin staples were removed on time. On the 10th day after surgery, noticed by laboratory tests a fresh slight rising in the leukocyte count and CRP value, but without increasing the temperature. Subsequently, there was once again an early normalisation of blood chemistry parameters of inflammation. Further diagnostics in the form of an X-ray radiograph of the chest and also an ultrasound of the pleura on both sides was rejected by the patient. After completion of Helicobacter eradication therapy, we continued the high dose of medication with the proton pump inhibitor initially unchanged. Meanwhile, the patient is symptom-free and again so far mobilised such that he can be released on this day of our inpatient treatment. 13 Leaving this existence… And returning… ❆ Recommended Treatment: We ask you to continue the regular wound checks. Otherwise, continuing the diet structure. Currently, the patient takes light snack. A regular bowel movement should be ensured, if necessary use a mild laxative, preferably of Sodium pico sulphate. The medication with the proton pump inhibitor should be initially continued, later in reducing dose. If necessary, continue the analgesic medication with a conventional NSAID in view of the above Hospital awareness course is strictly contraindicated, also likewise all potentially ulcerogenic agents should be avoided. Continuation of the mobilisation and initially the secretolytic medication. The pharmacological thromboembolic prophylactic should be continued for a week, to be administered preferably 1 x daily s.c. with low molecular weight heparin with occasional monitoring of the platelet count. © Maxwell Stirling, 10/2012! Last Medication: Pantaprozol ...............................................40 1-0-1 Acetylcystein Spray .......................................1-0-0 Sodium Dalteparin ................5000 IU 1x daily s.c. Metamizol .................as needed up to 4 x 40 drops Sodium Picosulfate ......as needed up to 20 drops With best thanks for the briefing and Yours sincerely Dinkelsbühl, 13/09/2012 14