buff and turf

the other day i read a post about the age old medical practice of the buff and turf. bearing in mind i also recently posted about icu, i was reminded of one of the worst turfs i ever saw.

it was during my icu rotation. we were on morning rounds with the consultant when a medical technologist came running in.
"there is a major disaster in casualties. can someone please come as fast as possible to help?"
naturally we all rushed over there. we were not prepared for what we saw.

in resus was a patient in severe shock. he was extremely pale and had almost no blood pressure. his abdomen was severely distended and sported a midline scar which had been crudely closed with a running nylon suture. the picture that is forever impregnated into my mind is the blood squirting out between the sutures. there were multiple streams of blood literally shooting up in a neat little line. as the patient rolled from side to side it reminded me of the sprinkler my parents had when i was a child. each line seemed to arch elegantly one way and as he rolled the other way, these fountains seemed to slowly follow. it may even have been beautiful in a sense if the setting was not so dire.

we jumped to work. one started cpr (it was needed) while another threw a high flow line into his subclavian vein (we used a schwann sheath). the third made some desperate, probably futile attempt to apply direct pressure to the abdomen. it seemed like a good idea at the time. during all this action we not so quietly and much less subtly enquired where the patient came from and why the surgeon on call wasn't waiting in casualties when he arrived. everyone pled ignorance. it seemed the patient arrived from a peripheral hospital without there being any warning that he was coming. with all the action that was all we discovered about his history then. our energies were concentrated on getting him to theater which we pretty quickly did. being the icu team, we then handed over to the guys in general surgery.

later we heard his story. the patient had been shot through the abdomen. at the hospital he presented to he was taken to theater. there the medical officer who operated him started by repairing all the bowel injuries. thereafter he decided to explore the retroperitoneal haematoma. as it turned out this action would reveal that the bullet had gone straight through the ivc.

i can just imagine his thought process. just before 'oh sh!t!!!' he probably thought 'i wonder what i'll find under here?' together with the 'oh sh!t!!!' which had no doubt evolved to 'oh f#@k!!!' he probably thought 'help!!!'. with this he decided to pack the abdomen and post the patient to anywhere away from where he was. we were that anywhere. in his raw panic he neglected to phone ahead and give any form of warning that this disaster was turfed to us.

truth be told i feel for the medical officer thrown into situations he is ill equipped to handle. but i find his overall actions difficult to justify. i think the reason he didn't phone is that he was afraid the academic hospital wouldn't accept a patient in mid operation for an ivc injury (his best chance which was slim under the circumstances was the operation he was undergoing at the time) and the rattled doctor wasn't willing to take that chance. all he knew is he wanted that patient far away from him and nothing was going to get in the way of that.


p.s the patient actually survived his operation and only died shortly after. well done to the operative team.

inferior vena cava

the inferior vena cava! we called it the black mamba. it lies to the right of the vertebral column. it drains all the blood from the lower extremities and the abdomen, delivering it back to the heart. when it is exposed, it has a dark blue colour. if you leave it alone, everything goes well. but if you hurt it, you are in for a whole world of trouble.

the first time i was nearly bitten was in my medical officer year. i was going to take a gunshot abdomen to theater...alone. just before, in an inspired moment, i phoned the senior just to tell him what was happening. when he heard the right transverse process of l2 had been injured by the bullet, he seemed disturbed. as i opened, he walked in. good thing he did, because the inferior vena cava (ivc) had been shot through and through at the level of the renal veins.

that was the first time i saw the ivc bleed. it's probably more accurate to say i heard it bleed. it sounded like a babbling brook. it seemed to spew blood, liters at a time. i could smell the adrenaline it caused (in the surgeon). somehow the surgeon got control and the guy made it.

then there was the time the consultant urologists pulled out a kidney for some reason. i was a senior registrar at the time. i happened to be in the vicinity (bad luck. i tried to run, but he saw me and called me into the theater). the urology consultant simply told me to scrub in. when i joined, he calmly tells me he injured the ivc. i looked under the finger of his registrar, indeed, the mamba was angry. he then told me that it was the realm of general surgery and therefore i should fix it. i could physically feel my adrenal glands go into spasm. what could i do? i fixed it, but not without much weeping and gnashing of teeth. afterwards i felt the usual parasympathetic overload after a severe sympathetic drive. i felt weak and tired.

but all the above examples are bearable in the sense that you deal with what is presented to you. not so when you are the one presenting it to yourself. a moment i wish i could forget and know i never will is when i myself nicked the mamba. and yes, boys and girls, he was angry, very angry.

without going into gory details, i cut it just above the liver where it dives behind the diaphragm to enter the heart. a word of advice, if you absolutely feel you must cut the ivc, this is pretty much the worst place to cut it.
i placed a finger over the hole, thereby stopping the bleeding. then i think i shat in my pants. seeing as i couldn't spend the rest of my life with my finger over the hole (although, i feared i might spend the rest of the patient's life with a finger over the hole) i started to repair it. step one was to call my associate to help. together we managed to get control and close the hole, but it was truly a terrifying few hours.

the point of this story is that in my line of work, occasionally (hopefully very very occasionally) you might find yourself in a situation where an action you take leads directly to harm or even death for another human being. to err is human, but when we err we can really f#@k up. i can honestly say it is a terrible and humbling realization.