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.

Wednesday, January 9, 2008

A Typical Day

This is an old post written when my youngest (now 1yr 9 months) was tarrying in the womb. The only thing that changed since then is the amount of entropy in our system and add 1yr 9 mos to the kids ages. I've decided that, E equals MC squared might only be true for subatomic particles (Don't quote me on that, I don't remember much physics). Anyone with small children knows that with a much larger mass and a much slower velocity, you get infinite energy. So here's a typical day in the life:

I wake up at 5 a.m., check to see if the kids haven't thrown off their blankets during the night. I go downstairs, drink some water. If I'm not completely wasted from the last on-call, I put in a half hour on the trainer (I'm an avid cyclist, more often than not I'm putting on pounds instead of miles), shower, eat something, drink some more water, make sure the kids are still covered and at 6 a.m., I'm at the bus stop waiting for the bus to Beersheba.

I'm usually connected to an MP3 player playing jazz or hard rock. This is on purpose, to drown out the senseless flapping of gums into cellular phones around me on the bus. I'm still surprised that people have something to talk about at that hour and even more surprised that someone else actually cares to listen.

6:30, I'm at work. Check e-mail. At 7 a.m., the morning report. The docs who were on call the night before relate interesting cases. The day's work assignments are announced. Most days I'm in the OR, today I'll be in the intensive care unit.

8 a.m. morning rounds in the ICU. The cases are presented; plans for diagnosis of problems and treatment are discussed. The guys who were on call go home for a well-earned rest, and the rest of us start the day's routine: Physical examination of the patients, review the lab results, make changes in the nurses orders. Take a patient to the radiology suite for a CT scan (a logistic nightmare involving mechanical ventilation en route, making sure all the IV drips are working, etc...).

Back in the ICU. Report the results of the scan to the director of the ICU.

Time for coffee!!!

More tasks to perform, call and schedule an ultrasound to rule out deep vein thrombosis (sort of like clogged pipes) for a young trauma patient. Change all the IV lines for a patient that has been in the ICU for a few days. Review the chest x-rays for all the patients.


Write a transfer letter for one of the patients whose condition improved enough to be transferred back to the ward. A call from the OR, a patient after a thoracotomy (an operation in the chest cavity) is being brought up to the unit.

The patient arrives from the OR. The patient is very unstable, blood pressure is low and dropping, the anesthesiologist who brought the patient reports that the patient was unstable during the operation and there where changes on the ECG that showed myocardial ischemia. A big operation and a heart attack to boot, the patient's prognosis is grim.

Start an IV with a pressor to boost the blood pressure, the blood pressure responds very sluggishly. The patient goes into VT (ventricular tachycardia, a potentially fatal arrhythmia), start CPR, call for assistance, click out orders to the nurses to prepare a defibrillator and to draw up syringes with drugs for resuscitation. Place the paddles on the patient’s chest, "clear!" I shout. Make sure no one is in contact with the patient and I administer an electric shock. A few seconds later, rhythm returns to normal but the blood pressure is still low. By morning, this patient passes away, the damage to the heart muscle was too severe despite all our efforts.

Evening rounds, we report the patients' conditions to the doctors on call, answer all their questions. Call the wife to tell her the good news: I'll be home on time today (for a change).

Catch the bus. Don't forget to hook up to the MP3 player (i.e. anti-flapping-gums-device).

Home, greet the kids, prepare dinner. Slow down, this is what I've been waiting for all week, a quiet moment with the family. My 6-year-old daughter (turbo-charged model) is talking 5,000 words per minute, excitedly relating the events of the day.

My three-year-old son asks me to build a Lego car with him. After a couple of hours of sacred quality time, it's bath time. Time too precious to waste, I talk to my son, he tells me of the goings on at nursery school that day. While I dress our boy in pajamas, my wife bathes our daughter.

Story time. I read one of our favorites: Meir Shalev's "How the cave man invented entirely by chance Romanian kebab." I kid you not, it really is a children's book. At some point, I'm woken up by my son poking me in the ribs, "Daddy, wake up and finish the story!" Yet again, I fell asleep while reading a story aloud.

Finishing the story, I sing some lullabies, and my son falls asleep. Now I can shower. I go to my daughter's bedroom, she tells me more about her day, I kiss her good night. I go to our bedroom. It's 9 p.m. and I'm exhausted. My wife is reading a book. Slipping under the blanket, I look over at her, somewhat puzzled. "You look familiar, do I know you from somewhere?" We discuss the day's events, things that need to be done tomorrow. I ask her how she's feeling - she's 40 weeks pregnant.

The kid still doesn't want out. Apparently he's waiting for improvement in the weather. I turn out the light. We cuddle and fall asleep.

Five minutes later the alarm rings, incredible, it's 5 am...

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