Saturday, June 8, 2013

My Night with Paula

                  

I don’t think I’ll ever forget that night. We were together for hours, standing and sitting near each other, hands mingling together as we kept at it, long and intense; endless. The minutes stretched into hours, but we would not give in to fatigue. Finally, I looked up and stared into her soft hazel eyes. I’m not sure what I was looking for: maybe some soft words of encouragement or some good thoughts. She seemed to sense my anxiety, my deep needs as I stared into those eyes. It wouldn’t have taken much, maybe just a nod of her head, to keep me going. It seemed like an eternity, but then those eyes lit up and the light danced in them. Then I heard the words I’d been waiting for:

“Why don’t you just cut the damned leg off?”

“Harrumph,” was my reply and bent my head and went back to work, doing my best to salvage poor Melvin’s leg.
Melvin was a retired mailman. He was used to walking and the blocked artery prevented him from pursuing this favorite activity. He could barely walk fifty feet when I first met him.
“The pain in my calf is just terrible, Doc,” he reported. “I can’t do anything anymore, Can’t you help me?”
He went through the usual evaluation which revealed a fairly straightforward occlusion of the right superficial femoral artery with pretty normal arteries beyond the blockage. He still smoked cigarettes and had hypertension. In short, he was the typical vascular patient. I had advised him to give up smoking and he had cut back from two packs per day to half a pack; an improvement, but not would I would have liked.
His symptoms warranted surgery and he underwent and uneventful right femoral-popliteal bypass, six months before Paula and I were to join together for our eventful night together.
Melvin called my office complaining of severe pain in his leg the day before. A quick exam confirmed that his graft was occluded. Off to the hospital he went, a friendly Radiologist whisked him to the angio suite where catheters were inserted into his arteries and an attempt was made to dissolve the offending clot. Unfortunately, the thrombolysis didn’t work. The catheter could not be properly positioned in the graft and a day of infusing thrombolytic medication did nothing. Melvin’s leg was still ischemic.
Surgery was the next option. A simple thrombectomy. Open up the groin run the Fogarty up and down a few times, close the artery and be done in less than an hour. The best laid plans…
The whole affair did not begin well. I had been waiting for hours to begin the surgery. I called the OR at about 5:00 pm and asked Melissa, the head nurse on evenings, when I’d be able to start my case. Melvin’s foot did have some circulation and he was not in any immediate danger of losing his it, but he was having considerable pain.
“Come on now,” was Melissa’s answer.
So, I made the short drive over to the hospital.
“You have to wait for Dr. So and So to finish,” she announced after I arrived.
“But, you told me to come in now,” I protested.
“I thought the other room would be done and anesthesia can only run one room,” she replied.
Melissa did this over and over, that is tell me to come to do a case when it really wouldn’t start for hours and I soon learned not to come in unless they were definitely ready to start. But, for Melvin I waited and waited and waited. Almost three hours later, at about 8:00 pm, we were ready to start. Initially, Martha was the surgical tech scrubbed on the case, but she had to leave at about nine, replaced by Paula. We had barely started at that point.
The incision and initial dissection were unremarkable. There was the expected scarring, but the graft was easy to expose and the dissection of the scarred in common, superficial and profunda femoris arteries was not unusually difficult.
“This shouldn’t take much longer,” I said to Paula as she tied her gown and ambled up to the table. “Hopefully just run the Fogarty up and down and we’ll be done.”
“Good,” was all she said.
With the arteries exposed and controlled and everything in place, the real operation was ready to commence: give some heparin, clamp the arteries, open the graft close to the anastamosis to the common femoral and we’re on our way.
As expected there was thrombus (clot) in the graft. The clot we could see was pulled out and then a #4 Fogarty catheter is passed, distally first, removing a long snake of maroon thrombus, a large amount first, and smaller amounts with each pass. There is a bit of resistance with the last pass, but no more clot is retrieved and we are rewarded by bright red blood filling up the graft, suggesting that the artery is open.
Now, the other way. The first pass restores some inflow, but not completely as the blood weakly squirts out, instead of the blast of blood under pressure one would expect from an unobstructed femoral artery. Two more passes and there is a sudden burst of bright red blood as normal inflow is restored.
Everything is going well, just close it up and we should be done.
I smile at Paula who is sitting across from me.
“We should be done soon,” I comment.
“Good, because it’s past my bedtime,” she replies.
OK, sew up the graft with some 5-0 Prolene open her up, good pulse here and down the graft. Check the foot: no pulse.
“Do you have a Doppler?” I inquire of the circulator.
“I’ve got it already,” Paula states.
Always on top of things, that Paula.
I listen at the ankle. There is a weak regular pulse, audible, but not what I would expect if the graft was open. I listen over the graft and here the short staccato of the pulse, like waves beating against a closed door.
“Something’s not right,” I say out loud to no one in particular. “Give me something to open up this graft again.”
And, we start anew.
Pass the catheter, restore backbleeding, no pulse. OK, let’s open up at the distal anastamosis. The old, healed wound at the distal thigh is incised and carried down to where the graft is encased in scar tissue. This scar is gingerly cut away, exposing the graft material which is cleaned down to the connection at the popliteal artery. There is a pulse in the graft, but none in the native artery.
Next step: clamp the graft and open the artery just above the distal anastamosis. The inflow is excellent and there is some backbleeding finto the graft. Pass the catheter and it stops about ten centimeters into the graft. There must be some occlusion at that level. It’s time to stop for a moment and look at the arteriogram.
The artery is open on this film. What’s going on. Must be a dissection of the artery.
“We may be here a while,” I remark, once again to no one in particular. I look up at the clock, now reading 10:15 pm.
“You may want to call in the call team,” I remark, “we definitely will not be done by 11:00.”
“That’s me,” Paula reports.
“I guess we’re in this together,” is all I can say.
I return to the patient and start to dissect more. Paula follows my every move, handing me scissors, clamp, pick-ups, right angle, vessel loop, whatever I need without my asking, anticipating my every need. I follow the graft down to the artery and begin to tease it away from scar tissue and delicate veins which entwine around the artery. Careful, try not to tear anything.
A pool of dark blood wells up. Suction…suction some more. There’s the culprit: a branch from one the veins. Clip, clip, a bit more suction, on with the fight. I’m reaching the limits of what I can dissect around the knee. The artery is diving deep behind the knee, a difficult place to expose. But, it looks like there is enough artery beyond the junction with the graft to work with.
Clamp,. Clamp, cut and look inside the artery. There is no question that the artery is dissected, a bad thing in this case. What it means is that the lining of the artery, or intima, has lifted away from the muscular wall, creating a false passage. I’m left with two options: try to repair the dissected artery or bypass to a different spot, probably below the knee.
At this point I have to confess that I’ve never had much luck with repairing arterial dissections, although I keep trying. I don’t know if it’s my technique or if I underestimate the extent of damage. All I do know is that I’ve tried to do it over and over again, but I never learn, it never works and I always end up redoing the bypass at some point away from the damaged artery.
Even with the above disclaimer, I try to repair the artery. A number of interrupted 7-0 sutures tacking the back wall down, then close the artery and open the graft and, voila, a pulse appears in the artery.
Good, good, let’s close up and be done with this case. But, it was not to be. After five minutes the pulse disappears and I’m back to square one. The clock now reads 1:30 am. I stare at the arteriogram and proceed.
Paula looks up at me from across the table, sighs, and hands me the scalpel. She’s too slow this time, however, as I make the next incision below the knee using the cutting mode on the electrocautery, a sign that I am getting a little frustrated with the whole affair. Deeper and deeper into the leg, through fat, fascia, around muscle, more fat, more fascia until a bundle of veins is exposed. More gingerly dissection identifies the popliteal artery below the knee, a hard pipe of calcified artery that, although appearing to be adequate on the X-Ray will not serve my purposes, because it is severely diseased.
Maybe a bit more proximal? Dissecting up a bit exposes more of the same. Now what? It’s at this point Paula offers her words of encouragement.

“Why don’t you just cut the damn leg off?”

It’s now getting close to 3:00 am and I’m not much better off than when we started. One last effort: bypass farther down the leg, to the anterior tibial artery, which looks good on the arteriogram and runs all the way into the foot.
At this point I recall a case I scrubbed on as a resident. I was helping one of the vascular surgeons do a similar case. This particular surgeon was one I considered to be of marginal skill at best. He had filleted the leg open in the groin, thigh, proximal leg and was about to go to the ankle when I asked:

“Do you think this will work?”

Surprisingly, he didn’t become angry or command me to leave the OR suite, much to my dismay. He just shrugged and replied that sometimes, in Vascular Surgery, you do what you have to do, because the alternative is loss of limb or life.
Paula and I embarked on the next stage of our journey as I began to expose the anterior tibial artery. The artery was small as expected, but appeared adequate for my purposes. I harvested a segment of saphenous vein from the groin and thigh, long enough to run from the graft in the thigh to the mid calf. Next I opened the artery, greeted by some back bleeding. I embarked on the first anastamosis, vein to artery, with the vein reversed to avoid the problem of its valves. Next the vein was tunneled from the anterolateral leg to the medial thigh and then the next anastamosis was done, graft to vein.
And, the moment of truth, the clamps are removed and…nothing. No pulse in the new vein graft. I examine the graft in the groin, where there is a pulse and in the thigh, where there isn’t.
Maybe, it’s something simple, just some thrombus in the graft. The way this case is going there are probably gremlins inside the graft.
From the graft in the thigh I pass a Fogarty catheter proximally and distally and, thankfully, some clot is removed from the proximal graft. Now there is excellent inflow. The graft flushes easily with no resistance. I suture the graft closed and, crossing my fingers and toes, open it up to allow flow. To my, and Paula’s, great relief there is a good pulse in the graft and in the artery beyond the graft.
It’s now 8:00 am.
All that remains is to make sure there is no bleeding and close it up. Brian, Paula’s relief comes in and offers to take her place. To her credit, she volunteers to stay and finish what she has started. We put the last dressing on at about 9:00 am. We both leave for a much needed bathroom break, after which I sit down to the tedium of writing orders and dictating the marathon operative note.
Melvin recovered uneventfully. His graft remained patent for about eight months and then re-occluded. This time it was reopened by our Interventional Radiologist. It eventually occluded again sometime later and he learned to live with the pain for a while. Eventually, he had to undergo a below knee amputation.
He underscores what one of my teachers told me years ago.
“All vascular surgery is palliative. What we do staves off the inevitable.”
As I think about these words now, it strikes me that what he said can be applied to all of medicine. What we doctors do is purely palliative. The end result is the same for everyone and the best a physician can do is put off, for a time, the inevitable.
I did see Paula before she left that morning; both of us were exhausted, completely and totally spent, but also quietly satisfied after the night’s affair. She has continued to assist me over the years, now as a Licensed First Assistant. She remains one of the best assistants, perhaps because she understands the way I operate better than most, one of the fruits of our night together.