It was one of those cases. It was probably hopeless from the beginning, but he was young and we had to give it a go. As soon as the abdomen was opened everyone knew things were bad. There was blood everywhere. It took a while to even see the damage to the liver because I needed to get rid of the blood in the abdomen before I could see anything. However, once I saw the liver even I was shocked.
The liver was ripped apart with one laceration dropping down to where the IVC sat menacingly behind it. It seemed to spit and splutter at my efforts to bring the bleeding under control in defiance of me. But I did what I could as fast as I could. At times like this the unsung hero is the anesthetist. If he can’t get fluid and blood into the patient fast enough, no matter what the surgeon does, it will be in vain. That day the anesthetist was great. Somehow he kept some semblance of a blood pressure in the patient against overwhelming odds.
After a while with large compressing stitches in the liver, the worst of the bleeding finally subsided. Usually, unfortunately, at this stage of these operations we are confronted by another problem. You see with massive blood loss the patient loses or uses up all their clotting factors and platelets. Even if the hole in the vasculature is closed, there is a general ooze of blood from pretty much everywhere. To attack each ooze with an injudicious suture not only doesn’t help a bit, but it wastes precious time that could be better spent in ICU replacing these vital factors. I made the call.
“There are no more surgical bleeds that I can control here. I’m going to pack the abdomen and send him to ICU to optimise his condition and we’ll take him back in a day or two.” The anesthetist looked up.
“If you say so, but he is not looking so great here.” He pointed at the monitors.
I packed and closed. The gas monkey continued throwing every available fluid into his system as fast as he could.
“I’m just going to top him up as much as possible before we transport him to ICU.” he informed me. He was definitely worth his salt, this one.
This is now a time that the average surgeon doesn’t like. We are not the stand back and wait types. We struggle to sit still and give it time to see what happens. But sometimes it is needed. I didn’t have to wait too long before the the gas monkey told me what was happening.
“Bongi, this guy is not improving on the fluid and blood I’m giving him and his abdomen is distending. Are you absolutely sure there is nothing inside you can’t make better?” The problem was I knew there was nothing I could do that I hadn’t already done. However the anesthetist’s observations were undeniable. The question was was there something I had missed or was the patient so far gone that he was lost already? It was clear that despite a valiant and heroic resus effort from the anesthetist, the patient was clearly dying. There was only one thing to do. We had to open and look again.
We opened. Immediately I knew everything we did from here on out was futile. The patient was in irreversible shock and had absolutely no clotting. There was nothing that I had missed from a surgical point of view which meant there was nothing I could do. After poking around a bit I packed and closed again, but this time with a heavy heart. I knew what was going to happen. The anesthetist also had no illusions about where we stood, but we both continued to go through the motions.
The motions led us eventually down the deserted passage way in the middle of the night to ICU with a patient that was sort of alive in the broadest definition of the word when we left theater. Both the gas monkey and I didn’t want to check the vitals during that quiet sombre journey. What did it matter? We knew what was going to happen and we knew it was out of our hands. The only questions were where and when it was going to happen if it hadn’t already happened. So when we entered ICU we were quiet and reserved.
When ICU receives a new patient, there is usually a flurry of activity and this was no exception. All the sisters descended on us like a swarm of bees, each going about their respective duties. Soon the patient was connected to the ventilator and the reassuring rhythmic sound of it pumping away filled the room. However once his pulse oxymeter and blood pressure cuff were connecter they did not give any comforting sounds. Quite soon their alarms were blaring away. I glanced at my anesthetic collegue and we both shook our heads. We had done what we could. The ICU sisters hadn’t seen what we had seen. All they knew was we had delivered this patient and things didn’t look good.
“I can’t get a blood pressure. I can’t feel a pulse. Crash trolley!!!” She yelled to one of her juniors who scurried off in obedience. Neither I nor the gas monkey moved. We just sat there, defeated at last.
“Doctors, this patient is dying! Aren’t you going to do anything?” I laughed. I didn’t mean to and I think it was more a nervous laugh. I was too emotionally exhausted at that moment to react appropriately. My colleague also laughed, but more at my response than the situation, I think. He then explained that what could be done had been done and any further resus would be in vain. We turned off the ventilator.
and so there we sat, feeling like the very life had been wrung out of our souls as the patient expired and some of the sisters looked at us as if we were heartless bastards for laughing.
*This blog post was originally published at other things amanzi*