Tuesday, January 22, 2008

sunday, bloody sunday

I was supposed to have the whole weekend off. Quite a rarity for a surgical resident, acutally. So imagine the dread that I woke up with when my pager went off on Sunday at 0115. The resident responsible for the page regretted to tell me that the vascular attending had accepted the transfer of a patient with a ruptured AAA and that the other on-call people were far to busy with traumas to scrub the case. I'd have to come in and the patient was on his way.

Maybe it was being just woken up with really bad news. Maybe it was knowing that I was going to spend Sunday studying for my in-service training exam that is coming up with week, and now I probably won't. Maybe it was knowing the futility of the proposed surgery and there is a 50% mortality associated with it and there is likely an even higher mortality with the on-call attending. Maybe because I was going to have to scrub with the attending who bathed me in blood a few months ago. But for whatever reason, in a very uncharacteristically surgeon move, I started to cry.

I pulled myself together, got my contacts in, and drove to the hospital. When I arrived, they were checking him at the front desk of the OR. He was begging for another pillow.

We opened the abdomen and didn't find an intraperitoneal rupture; rather there was a quite extenisve retroperitoneal hematoma. In addition to the infrarenal AAA, he had aneurysmal extension into the right common iliac and a separate common femoral aneurysm. Just to add something interesting to the mix, his INR was 3 (normal is 1) because he was on coumadin for his chronic atrial fibrillation.

Just when we were gaining control of the neck of the aneurysm, my attending and I had a very interesting exchange:

"You know, I should have probably never accepted this transfer."

"Why, because of his INR?"

"Yeah. That and the fact that he was turned down by seventeen other surgeons before they called me." Seventeen may have been a bit of an hyperbole, but you get the point. I certainly did.

"Well, then why did you accept him?" A little insolent for me, but it was 3:30am, after all.


"Just before I received the call about this patient, I had won a $600 hand of poker." The only way I took that unfinished thought was that he'd just had a bit of luck and thought it would continue.

I'm sure you can predict how things went from here. We had some hairy moments of hemodynamic instability in the operating room. 16L of blood loss; 4.2 of which we returned. Dozens of blood and blood products. A tube graft was sewn in; we never even laid eyes on the right iliac. Due to the massive and ongoing fluid resuscitation, his bowel was too edematous to close the abdomen, so we had to place an abdominal wound vac on.

I told my attending we weren't dry when we placed the wound vac. (Meaning that there was something still actively bleeding.) He insisted that he was diffusely oozing from all exposed surfaces from his hypothermia and coagulopathy.

In the recovery room, the wound vac put out another 6L. The family didn't want us to go back to the operating room to find the source of the bleeding. We stopped transfusing and he died there.

I am not cut out for vascular surgery. I admit it.


rlbates said...

What a tough bit of luck, all around.

Anonymous said...

Maybe the problem is with your attending, not you - spraying blood on the chief, closing over active bleeding. . . Although I know my attendings' practice seems to be to take a shot at every ruptured AAA, because you know they're going to die anyway. Did you have a CT going in that showed those other aneurysms?

One of our vascular attendings the other day did a case that lasted nearly 24 hours. Only the patient's youth allowed him to survive - not without complications.

lights n steel said...

I'm sure one of the reasons he chose to accept the patient was because this was his only chance at living. We had a CT angio at the outside hospital that showed the other aneurysms. Although we didn't need it for the femoral one; his groin was pulsing...

A 24 hour vascular case? Woah.

make mine trauma said...

I have scrubbed and assisted on AAA's that live and go home. Sometimes patients you would never expect to make it, do. This patient however sounded doomed from the start! Guess he chances were probably the same with or without surgery.

Bongi said...

sometimes they have a chance. but if he had been turned down by a whole bunch of hospitals i assume he'd lost a lot of time? lowers the chances too. i remember one ruptured aaa our fellow decided not to operate because he was 89. the next morning not only did i find him alive but asking for a discharge. who would have thunk? we probably should have had a go at it. he died only after 2 days.

Bongi said...

by the way, please submit this post to surgexperiences at http://blogcarnival.com/bc/submit_1852.html

you might consider making yourself available to host surgexperiences some time in the future???

Michael D. Miller, MD said...

Hope you're doing better after this. Got to wonder about his PCP/Cardiologist and how his INR got to 3, and whether all the aneurysms (and their size) where known to his regular doctors.... clearly a planned surgery would have had a better chance for the patient.

Also, since you don't have contact info here, I've just started a blog you might be interested in - covers more policy/political aspects of US healthcare - see www.healthpolcom.com/blog and feel free to subscribe and/or blogroll it - I've added your blog to my blogroll.

Best Wishes, M

Alice said...

I noticed on Dr. Schwab's blog that you are still around. I was afraid that, like many of your friends, you'd been chased out of the blogosphere. Please post some more when you can, your stories are wonderful.

rlbates said...

I'm with Alice. Have been missing your posts. Hope you are well and just busy. Take care.

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Nurse and Hospital Stories said...

"I am not cut out for vascular surgery. I admit it."

Ah, may that patient rest in peace, eh. Sad and bloody story. :(

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