Friday, February 13, 2009

orchestrator

team work in an operation is essential. usually i can just get on with my job and trust the anaesthetist to keep the patient going (alive). i don't have to worry too much about him. however in state sometimes i need to orchestrate everything.

the case was unusual. blunt trauma to the abdomen often causes the left diaphragm to burst, causing the intestines to migrate into the chest. this time the trauma was to the chest. the diaphragm burst from above. the x-ray picture was the same with the stomach in the left chest, but at operation it looked quite different.

they had apparently already done a full resus in casualties before even getting the patient to theater, so the patient wasn't in the best of shape.

the anaesthetist was a doctor from some outlying peripheral hospital that usually didn't do more than very simple cases and didn't even have a diploma in anaesthetics. he was doing his best and at least trying to meet a need in our local state facility. i opened in the midline. i found it a tad disturbing to find the heart free in the abdomen, just above the liver. i considered saying,
"i don't think this is supposed to be here!" but i thought better of it.

the diaphragm was destroyed. the pericard was destroyed. the heart had wondered off to the left and the lung had shrivelled up to hide somewhere out of sight. it didn't take a genius to realise this was not good. i realised this was not good.

i started the repair. then the heart stopped. it was easy to diagnose. i could clearly see the heart in front of me. i informed the gas monkey (anaesthetist). he looked at me. i put my hand around the heart and started to squeeze. the gas monkey looked at me. i realised he simply didn't have the beginning of an idea what to do. i realised this was not a team work situation. i needed to take control of everything. i was the gas monkey consultant suddenly. i took control. i orchestrated what needed to be orchestrated.

"you!" to the gas monkey, "give adrenaline now! you" to house doctor floating around like an unwanted fart on the wind, " draw up x ampoules of adrenaline and put it into y ml saline!" all the time i compressed the heart. now i have occasionally compressed a heart against the sternum from inside the abdomen, but seldom have i stood with the heart completely in my hand. i quickly adjusted to the correct amount of pressure to apply directly to a naked heart. it is quite a bit less than one on the other side of a diaphragm and decidedly less than one hiding behind a sternum. soon i was applying compressions with thumb and two fingers. that was all the pressure that was needed.

the adrenaline did the work and the patient came back. we went on. then things went south again. this time i put my hand around the heart and clearly felt the gentle vibrations of ventricular fibrillation.
"you!" to the wide eyed floor nurse "get the defibrillator now! you!" to the surgical medical officer, "get ready to shock and give me ample bloody warning because if you shock me i will not be happy!" all the time the heart was cradled in my hand with my three fingers doing the necessary.

we defibbed once and the patient came back.

the patient crashed twice more and i orchestrated the relevant resus. i then sent the house doctor to icu to ensure they prepared an adrenaline infusion and started closing. the patient had had better days but she was alive. i closed, gave the last necessary instructions and left.

when working with true gas monkeys we work as a team. but it is times like these when i work with junior doctors who find themselves in deep water that i remember what a priveledge it is to have well trained colleagues.

9 comments:

rlbates said...

Yes, it is truly nice to have well trained colleagues so you only have worry about one job and not all of them.

Amanzi Down Under said...

Working in the dump that is Edendale Hospital, I distinctly remember an Anaesthetic doctor (diplomat) refusing to do an anaesthetic because according to her, the surgeon wasn't polite to her. I can imagine her walking out on you, heart in hand, if you ever adressed her as "you!".

Did you politely ask your anaesthetic doctor to kindly do their job?

make mine trauma said...

What an unexpected find! Even with the diaphragm torn open, I have never seen the heart in the abdomen. So it was because the pericardium was torn that it traveled so? Forgive my ignorance, but here, thank goodness, that case would have warranted a call to the heart surgeon and an anesthetist familiar with heart operations. You really and truly do amazing things above and beyond what should be expected of you, working in such an underprivileged area.


cool-my word verification is INTEROP

Jabulani said...

If you've ever been to a recital, then you'll have heard the warm- up. It is a cacophony of discordent sounds where each musician is "on their own". However, the second the conductor raises his baton and takes charge, order is restored and fabulous music ensues.
In my humble opinion, it is a testament to your phenomenal skill as a surgeon that you can carry out your job at the same time as overseeing the jobs of those around you. Particularly when you (literally) have someone's life in your hands! There's a John Williams score that, in my mind, is now synonymous with you ...

Bongi said...

down under. i was not overly polite, but at the same time not rude. i think the gas monkey was only too happy to be told what to do. he had the savvy to know he was in deep water.

mmt, the inferior pericard was destroyed, but the left pericard was also gone. the heart, strictly speaking was still in the chest but exposed and far over to the left. the remnants of the diaphragm had retacted up giving the impression of the naked heart being below the diaphragm. i did phone the thorax guy and he gave telephonic advice. he didn't join me though.

mi said...

*clap, clap, clap*

well done, maestro!

amanzimtoti said...

So what exactly can the thorax guy do that you can't (except say pericardium) because it seems you're always doing the thoracic cases in state.

SeaSpray said...

What an awesome post Bongi!

You sound like an terrific doc and your patient was very fortunate to have you working on her and orchestrating the team.

Bianca Castafiore said...

Please accept my well-considered, and long thought-out, expression of... awe. Then again, those great vessels attached to the misplaced organ must be mightily designed and forgiving of a fair amount of what can only be called "torque."

So it is "awe" all around!