the sentinel

anyone who follows this blog will know i have a tenuous relationship with the ivc (here and here). it is something i've seen only too often and each time it has me on edge. somehow i just can't get used to being up close and personal with an ivc that seems to want to bleed. but even i can laugh at some of our interactions.

i was the senior registrar so when the bone doctors decided to do a spinal fusion at the 4th and 5th lumbar vertebra and they wanted someone to expose the spine for them from the front, i was their go to guy. only problem is i didn't know how to do it. having been in surgery for long enough, it came naturally to me to show no weakness. i couldn't tell them this. i reasoned to myself i'd discuss it with the prof and if he felt i needed assistance then he could offer to help. looking back it wasn't the best thought out plan, all things considered.

the operation was booked for two days time, so the next morning i went to the prof's office and told him that i had been asked to help with exposure for a spinal fusion at level l4-5. he seemed almost not to hear me.

"good." he said as he continued with his work.

"only thing is, prof, i've never done it before." i considered telling him i'd never even seen it before but that was implied in the first statement, i thought. "should i go transperitoneally?"

"do what you are more comfortable with." great help, i thought. well transperitoneally (through the abdominal cavity) it would be then. the abdomen was after all my stomping ground.

the orthopaedic consultant who was going to do the operation was a bit of a legend. he was this super genius whiz kid that everyone doing intermediates was afraid of. he pretty much knew everything about everything and would always be able to dig out a question that you couldn't answer if he wanted to. luckily intermediates were way behind me so i didn't need to worry about offending him too much, but still it was a bit intimidating being asked to get exposure for an academic giant such as this man.

i entered theater at the predetermined time. there were about 3 orthopaedic registrars getting the patient ready. immediately when they saw me they asked how i wanted the patient to lie.

"put him on his back, " i said, oozing confidence, "i'm going through the abdomen." they nodded. and did so. once everything was ready we all started scrubbing and the sister started draping the patient. i tried to envisage what i would be doing in a while. i decided that i'd reflect the right colon up and pull the ivc out of the way, rather than reflecting the left colon up, which would mean i'd have more to do with the aorta. my reason had little to do with the blood vessels but rather had to do with the fact that the right colon can be reflected right out of the way whereas the left colon can't because it continues down to the rectum which is pretty much fixed. truth be told, the aorta is easier to work with than the ivc, but i just felt i'd get more exposure on the right. in my mind i was just trying to convince myself that it was going to be fine when the great orthopaedic consultant entered. he greeted us all and thanked me for my help before quickly going into the theater to make sure everything was in place. moments later he was back.

"the patient is on his back. are you going transperitoneally?" he asked. there was something in his question that bothered me, but this was not the time to seem unsure.

"yes, transperitoneally it is."

"for l4-5 fusion?" he asked it in such a way that the implied answer was that transperitoneally was not a good idea for l4-5 fusion. i thought back to the useful advice of my prof that i should use whatever approach i was more comfortable with. it occurred to me that this was an operation the prof possibly had never done before. besides if this legendary orthopod sounded like he knew something that neither i nor my prof knew, it was probably because he did know something that we didn't know. i felt my heart rate rise. but it was too late. i had no backup (the prof hadn't offered to help) and i would have to stand with my decisions.

"yes. we will be going transperitoneally."

"are you sure." i wasn't.

"of course i'm sure."

"well if you say so, but you are a braver man than me." he replied with a laugh. i felt my heart sink into my shoes. i just smiled.

i went through the abdomen. i flipped up the colon and exposed the ivc. i then mobilised it enough to pull it gently away from the spine....and discovered why transperitoneal approach is not good for l4-5. the ivc splits into two veins which drain the legs at roughly this level. the left one (left common iliac vein) crosses over the spine and when you try to ease the ivc away from the spine it gets pulled so tight it looks like it wants to tear off. but still i mobilised everything enough that their target area was nicely at least visible.

"there you are." i said with an air of i-told-you-so. "enjoy the rest of the operation. i'm outta here.

"what do you mean you're going?" said the giant. "you stay right where you are. it's your job to keep the ivc out of my way. you just stay there and stand guard over your ivc." this was starting to sound familiar and i was no longer happy to be part of it. but anyway, it wasn't as if i had a choice. besides, how bad could it get?

it could get pretty bad. i stood there with a retractor carefully in position putting just enough traction on my precious ivc without tearing the left iliac vein while the orthopod took the biggest badest instruments i have ever seen and ripped one entire vertebral body out bit by bit. now a vertebral body is somewhat tougher than an ivc and he used amazing amounts of power. i swear there were times he picked the patient off the theater table by his vertebra until a chunk was ripped off and the patient came crashing down again, all the while with me trying with all my might to not pull on the ivc with all my might and yet still keep it out of the way of that ferocious instrument the orthopod was wielding. in my mind he looked like a medieval barbarian with some sort of overly vicious weapon swinging around with just too much force. there were times when i thought he was going to pull the patient right off the table with me and the ivc being dragged down with him. i didn't only fear for that poor ivc but there were times i actually feared for myself.

after a while he got that condemned vertebral body out and replaced it with some sort of metal device. once that was in the ivc was allowed to return to its normal position. thereafter my frayed nerves also started recovering. once again had i stared into the dark eyes of the ivc and lived to talk about it.

p.s the patient survived too.

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.