Friday, January 25, 2008

Bleeding is bad for your health

Warning: The following post is not for the faint hearted. If you can't stomach descriptions of blood, innards and dead bodies, please read no further.

Trauma. It's the bread and butter, so to speak, of the business. Some trauma is inflicted by others, some is self inflicted. Some due to accidents. Some result from complications of surgery.
Surgery. One might call surgery controlled trauma. But when things go wrong, they go very wrong. A few days ago I was assigned to provide anesthesia for vascular surgery. The patients who present for vascular surgery are typically some of the most challenging to anesthetize. They might suffer from various combinations of chronic illnesses such as cardiovascular disease, diabetes,hypertension and others. The second case of the day was the exception to this rule. A relatively young man in his 50's scheduled for an endovascular procedure under a local anesthetic. Except for heavy smoking and severe narrowing of the internal iliac artery he suffered from no other diseases. The procedure involves puncturing the femoral artery in the groin and then threading a catheter to the iliac artery. The narrowing is then dilated with a balloon and then stented. I always examine these patients the day before because one never knows when such a procedure might be converted to an open procedure necessitating general anesthesia.
The patient came into the OR, I greeted him, put in an IV line applied the monitors, wished the surgeons and the patient luck and went to get a cup of coffee. I went back to the OR and the surgeons informed me that they were finishing up. I asked how it went, They said that it was difficult to place the catheter but they were successful and showed me the angiogram with the "before" and "after" images. But something was odd and my inner alarms were ringing. The patient was flexing his abdominal muscles making it difficult for the surgeons to apply a pressure dressing to the puncture site. However, the vitals signs were stable and the patient was transferred to the recovery room. A few moments later, his blood pressure began to drop. The chief of vascular surgery was close by, we asked him to check the pressure dressing to make sure that it was properly applied. At some point, the heart rate and the systolic blood pressure were the same: 40. The patient was in severe shock, somewhere there was ongoing bleeding. We rushed him back into the OR, anesthetized him and put in two big IV lines and began infusing warm fluids and blood. The surgeons found about a liter of blood in the groin and found a "bleeder" and ligated it. Despite this the blood pressure was stubbornly low. The odd thing was that the heart rate was normal. Usually, the body compensates for low blood pressure by increasing the heart rate. This reaction might be blunted in patients receiving medications to slow the heart's rate, or in athletes who have a normally low resting heart rate. But this patient was neither. I reminded the surgeon that the patient flexed his stomach muscles towards the end of the previous procedure. The surgeon replied that blood is sterile and doesn't cause a peritoneal (the membrane lining the abdominal cavity) irritation. I know that's what the text book says, but our patients don't always read the textbook. This patient was anything but textbook. At the end of surgery, I took the patient back to the recovery room still anesthetized and ventilated. The blood pressure was slowly improving and we began the next case, which was to be done under general anesthesia.
Surgery was about to begin when the intercom crackled, the previous patient was again unstable and his abdomen was distended, a sign of rebleeding. Another room was opened up for a third operation on this poor soul. This time, they found active bleeding and the retroperitoneal space contained about 3 liters of blood. A clamp was placed on the aorta and a search for the source of bleeding conducted. By this time, the patient was suffering from a consumption coagulopathy (that's when all the clotting factors get used up) and the patients needed about 9 units of blood and other blood products. They eventually found the source of the bleeding and treated it. The patient was taken to intensive care. I later called the ICU. the patient was stable and recovering nicely with no evidence of organ damage do to the prolonged shock state.
Yesterday I was on call in the mobile ICU of the MADA ambulance service. Usually I enjoy the change of routine. However, one of the more distasteful tasks that I am called to perform is pronouncing death. Here in Israel, we have no medical examiner for cases that occur in "the field". So that job is done by the doctors in the mobile ICU's. There was a terrible traffic accident outside of Be'er Sheva. A driver with very poor judgement tried to pass on a dark two lane highway. He was killed in a head on collision with a bus in the opposite lane. The medic that retrieved the body gave me the man's ID. By law, I must identify the victim with a photo ID. I see by the ID card that the victim is 50 years old, married with a two kids. I imagine he was hurrying home to his family. I open up the body bag. The man's face is very serene despite the violent end to his life. Hopefully he didn't suffer. And then, then I heard a sound which made me freeze. A cell phone was ringing. His cell phone was probably in a pocket of one of his garments, and it was ringing. Was it his wife calling him to chide him for being tardy? Perhaps she wanted him to stop by the market on the way home. I suppressed the urge to answer the phone and went back to my ambulance to fill out the paperwork.
The face. The peaceful look on the face of the deceased always surprises me. This victim reminds me of another victim. A few years ago, on a rainy winter night, four boys were playing on the railroad bridge at the entrance to Be'er Sheva. Who the hell lets their kids out in such crappy weather? The train came. The boys for some reason didn't hear it until it was too late. Three of them managed to jump off the bridge onto an embankment. But one didn't make it. The impact hurled him about 50 feet from the tracks. Again I was called to pronounce death. The state of the body was horrendous. Everything was broken, the arms, the legs, everything. All with weird angles to them. The top of the head, from the eyebrows on was not there. The medics found it 10 feet from the rest of the body. How odd, the face, the face was intact. It makes no sense.
Awful, just bloody awful.


Lioness said...

It's funny you should mention chemical peritonitis. I have two doctor friends whom I absolutely trust, and they both teach Physiology and Pathophisiology at university and one day I was studying with them and they told me about it, mucosas don't necessarily love free blood. Fast forward to a class where the teacher asks for possible causes of peritonitis and there you go, I was slaughtered by both the teacher and my fellow students bcs WHAT?!, blood is anatural a product- but dude, so is urea, and if my friends say it is so, IT IS SO.

We also have the textbook saying pertaining to cats, we tend to learn dogs as the template and one of my teachers is fond of saying, in English, "Cats don't read textbooks", they'll come up with variants of all possible things,mostly unexpectedly.

make mine trauma said...

I've always understood blood to be very irritative to the peritoneum....?

QuietusLeo said...

That's what I was taught, but not all surgeons agree with it.

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