Friday, November 9, 2007

blood. bath.

The other day we were scheduled to do a carotid endarterectomy, which is essentially where we remove the plaque caused by decades of eating Big Macs from the carotid artery. To review a little anatomy, there are two of them; one on each side. Cances are if you've got a messed up carotid on one side, the other side is also abnormal. Sometimes the lesion on the opposite side is not hemodynamically significant, meaning that that single vessel is sufficient to supply blood to the whole brain by itself. But if the plaque is causing stenosis over a certain percentage, the chance of stroke is much higher, or you've already had a stroke. So to prevent a stroke, we scrape out the junk.

During such a surgery, in order to preserve blood flow to the brain, you have to put in a temporary shunt. That's a fancy name for a piece of plastic tubing that diverts blood around where you need to work but gets plugged into the pipeline on the other side. Since these things are temporary, and too much clamping on an artery can cause damage in and of itself, sometimes they fall out. Which is usually ok, because the surgeon is an experienced, skilled vascular surgeon and he can handle the situation. But as this surgeon reminded the anesthesia resident, during this very case, "They don't call me Bloody Smith for nothing."

There we are, with our little plaque spatula (yes, it looks like a mini spatula with rounded edges), scraping away long-forgotten Big Macs, when our surgical field slowly fills with blood.

"Hmm... where do you think that is coming from."

"I'm not sure, you might want to check the shunt," I suggest diplomatically.

"Ok. Let me see about this clamp first."

Have you ever seen those cartoons where a firehose is attached to a firehydrant, the water gets turned on full blast, and the hose flies all over the place? That's precisely what happened, except it wasn't water coming out of the little tube. It was blood. Full blast.

Onto my neck. And my shirt.

I can feel the warmth running under my shirt.

Onto my bra.

Then dripping on my stomach.

I don't remember doing this, but people who were there said I took a step back, looked down at my gown in disbelief. I informed the surgeon that I had to leave. I had to go home and take a shower.

"But I need some help."

"I'll get you some help. But there is blood on my bra, and I've got to go home to shower and change. I'm sorry Dr. Smith, but I cannot spend the rest of the day in bloody underwear and I'm not about to go without, either."

"Do whatever you need to do, but I bring a gym bag and a change of clothes to work."

I left the OR, not knowing how to address the fact that he basically suggested that I bring all my toiletries, make-up, and spare underwear to work everyday in case he douses with me with blood. I walked through the hallways, in my blood splattered boots, looking for my junior resident to scrub in an help finish the case. People got out of my way as I passed them and uttered things like "Oh my God" and "Look at her shirt."

It wasn't a long walk, but it was long enough for me to recall all the stories I had heard from other residents about Bloody Smith in which they or their chief got some inexplicably large volume of patient's blood on them. When I arrived at our workroom, I asked my junior to scrub. I can't remember exactly what I said, all I know is that my voice was trembling with fury. And I said please. We walked back up to the OR, where everything was going fine again. I took off my boots, washed my hands and arms, and told them I'd be back.

I didn't even want to stop and look in a mirror. I just wanted to go home. I grabbed my keys and headed out to the elevators. I saw a nurse from the surgical floor. He looked at my shirt.

"How ya doin'?"


"I can see that."

I got off the elevator when another elevator arrived to the first floor at the same time. A woman looked at me and asked if I was ok. I said it wasn't mine.

Then I sat in traffic for 30 mintues because the city officials thought it would be good to take a three lane road down to one. The very road that leads to the freeway that would get me home.

I surveyed the damage when I got home. Blood all over my shirt. My bra. A little on my stomach. And my neck. At the level of my carotid. It's a good thing I didn't get pulled over for speeding on the way home; they might have dragged me in as a suspect for murder or something the way I looked. And I'm positive there was a murderous expression in my eyes.

It's not that I have never had blood on me or my clothes. There have been plenty of traumas where I didn't even have time to put a gown on and had to crack someone's chest with cheap-o unsterile gloves. This was different. One because it was on my BRA. That really grossed me out. And two, because this kind of stuff only happens with this one attending. And it's usually completely unnecessary.

P.S. The patient is fine. He got two units of blood in the operating room and was discharged today. He just had to stay to watch the end of Oprah.


imrickjamesbtch said...

we have a transplant surgeon here who is known for doing this during kidney transplants. he is also known for sticking residents with hepC and hiv+ needles. all the seniors refuse to scrub with him. thats why they call the 3 on that service "the pincushion"

UnsinkableMB said...

ewwww... yeah, i'm familiar with bloody cases. there is an ortho guy at my hospital who has the reputation of being like gallagher (you know the comedian who smashes watermelons with a huge mallet and splashes it everywhere?). even the circulator, anesthesiologist, and medical reps wear the waterproof gowns and eye protection!!!

by the way, imrickjamesbtch, that transplant surgeon sounds vaguely familiar... if there's more than one in this world, i'm scared!!!

make mine trauma said...

This guy routinely brings a gym bag and a change of clothes with him to work? Sounds like a self-fulfilling prophecy. And like he does it on purpose. Some sort of initiation ritual?

And I thought blood on my socks was gross....

Sid Schwab said...

I must say I have a hard time getting my mine around this one. The guy sounds like a jerk, and a bad surgeon. But I can't imagine just walking out of the OR because you were bloody. Ask for a change of gown and a wipe-off to keep the unsterile blood from dripping onto the patient. Ask them to call for your resident, if you must. But just up and leave? And walk all over the hospital all bloody? Don't get it.

I posted once about getting underwear bloody during a thrash of a case. Not pleasant.

Sid Schwab said...

mine = mind

Anonymous said...

Sid: I'm not exactly sure why I did what I did. I've replayed the whole thing in my mind over and over. I'm not necessarily proud of what I did, and I would like to hope that if that ever happened to me again I would handle it better. I am relieved that nothing bad happened to the patient.

The whole point of this blog isn't to profess what a cool surgeon I am or how adept I am in the operating room. It is simply a retelling of tales that happen to me -- as they are. Some are good and I am proud of them, and others are things that I would do differently.

You can be assured that the concerns you brought up in your comment echoed through my head long before you even posted them.

Anonymous said...

I had a similar incident happen during a CEA. This particular attending liked the shunts with balloons at each end (the name escapes me). He punctured the balloon with the 7-0 needle and the shunt came out and got me soaked as well as the anesthesiologist. (who was reading his stock quotes and should have retired years ago).

I wiped off and returned. I had it on my hat, my face, my glasses, my neck and down my shirt. I believe I had it on my bra, but not completely soaked.