Monday, March 14, 2016

A Horse is a Horse of Course...

                                      

Jeremy was a cowboy in the rodeo. He also was responsible for keeping me up for most of three nights in a row. He was the fortunate survivor of a run in with a very angry horse.
Animals are supposed to be our friends, at least dogs and cats, horses, pigs and cows. Some birds, the occasional snake and even tarantulas have been companions to humanity. Our encounters with these domesticated beasts are supposed to bring pleasure, happiness and feelings of wellbeing. Except, when they don’t.
Melvin was set upon unmercifully by two feral dogs, losing large chunks of skin and muscle from each leg and one arm before the beasts could be restrained. Sandy was a young lady tattooed from head to toe. She had a pet python who mistook her for his dinner one day and tried to swallow her whole. I see half a dozen patients every year with fever and painful swollen lymph nodes secondary to cat scratch disease. Bird bites, tarantula bites, dog bites and so many other bites have made it into the hospital over the years.
But Jeremy; he stands out. Maybe it’s because he showed up in the ER very early in my career in private practice; maybe it was the running battle between his divorced parents, maybe it was the conversation with Dr. Red Duke, or the lack of sleep I accumulated over the four days it took to stabilize him. Probably all of the above combined to make him one of my more memorable disasters.
I had been out in private practice for about four months and I still had the feeling of invincibility common to surgeons as they leave the safety of residency and head out to save the real world.  It was eleven pm when the phone rang.
“Dr. G this is Dr. F in the ER. I’ve got an eighteen year old man here who got kicked in the right side by a horse. His heart rate is 130 and BP is 90. There’s a big area of swelling on his right side. He’s on his way to CT as we speak.”
“OK, thanks, I’ll be in to see him,” I answered. I turned to my wife.
“I need to go to work,” I said.
“Surgery?” she asked.
“Don’t know. I hope it’s nothing major.”
I pulled on some clean scrubs and left.
Jeremy was just finishing his CT as I arrived. As he was wheeled back to the ER I scrolled through his scan.
Broken rib, looks like a pretty big subcapsular hematoma of the liver, not much else.
This was my reading of the scan, but usually I was pretty accurate, as I had spent the last two years of my residency reading abdominal CT’s with the senior Radiology residents.
The Radiologist’s official reading was in agreement.
Jeremy was awake and alert, complaining of pain in his right side. He had been competing in a local rodeo and one of the horses decided nobody was going to ride him and decided to vent his anger on Jeremy,  delivering a solid kick squarely to Jeremy’s right side. There was a big bruise on his right side and I was sure I could make out the imprint of a horseshoe. Certainly not lucky for Jeremy.
Jeremy’s Dad was at his bedside showing nothing but the proper concern. Mom and fireworks would come later.
Jeremy stabilized after a couple of liters of IV fluids and I decided surgery was not needed at this time. I tucked him away in the ICU and was back in bed by 2:00 am.
Later in the morning Jeremy was looking fairly stable. Heart rate was around 110, blood pressure was 110/70, urine output and oxygen saturation were good. His hgb had dropped for 14 to 10.5.
“Looks like he’s pretty stable,” I reassured his dad.
“His mother will be happy,” he replied.
“I haven’t met his mother yet,” I answered.
“She’s been away, on a business trip. She’s flying in this afternoon and will be here later.”
“Oh, well I guess I’ll meet her later. I’ll check on him this evening,” I added and I left to attend to other sick people.
A few hours later a message came to call the ICU regarding lab results.
“Jeremy’s hemoglobin has dropped to seven,” the nurse reported, “and his heart rate is 125. Blood pressure is 100/60.”
“Give him two units of Packed RBC’s,” I ordered.
Looks like he’s going to need surgery. I hate operating on the liver.
That was the truth. I loved operating on the biliary system, pancreas and everything else around the liver, but the liver itself was one of my least favorite organs to work on.
Maybe it’s because you can’t really take it out. Every other intra-abdominal organ could be removed if necessary, its functions then assumed by other organs or replaced with medication. The esophagus can be replaced by a segment of colon or even small bowel, stomach can be reconstructed, much of the bowel can be resected with impunity, dialysis can replace kidneys if necessary, there is insulin and enzymes for the pancreas, but the liver is different.
No other organ does its job. It metabolizes and excretes bilirubin, detoxifies noxious chemicals releases glucose along with so many other functions. Liver transplant is the only real viable alternative if a liver fails or has to be removed. I was not really anticipating having to remove all of Jeremy’s liver, but the point is that the bleeding needed to be stopped and sometimes this can be problematic when dealing with the liver.
I considered repeating his CT scan, but decided that this wouldn’t change the inevitable.
So the blood transfusion was started and he was scheduled for surgery. It was six thirty when I went to explain the situation to his parents, both Mom and Dad now present.
“You let him ride in the rodeo. I told you to stop it,” I heard Mom hissing loudly.
“He’s an adult. I can’t live his life,” Dad replied in more of a whisper.
“You could if you were more of a man,” Mom answered, the hissing growing louder.
I took that moment to interrupt and introduce myself to Mom.
I’m Dr. G, I’m pleased to meet you,” I began, addressing Mom. “I think you know that Jeremy needs surgery. I’d hoped he would stabilize, but that hasn’t happened.”
“I’d like to send him to the Med Center,” she stated.
“That would be fine with me,” I answered, “but he’s not stable at the moment. He really needs to go to surgery. I think we’re just about ready to start. Afterwards, when he is stable, we can try to arrange for a transfer.”
She looked at me with an expression which said, “You better take care of my Jeremy or else…”
I left the worried family and met the OR crew as they began to wheel Jeremy down the hall from ICU to the OR.
“Don’t worry,” I reassured him, “we’re going to take good care of you.” This has been my standard line to worried patients over the years, short and to the point, but very effective.
Jeremy was fairly stable as I made my long midline incision. His heart rate was 120, BP 110/60.
Upon entering the abdomen I was greeted by blood, blood and more blood, dark blood wafting up from between loops of slightly pale bowel. There was more blood around the liver, redder, fresher along with large congealed clots.
We, that is myself and my assistant, scooped out all the blood and began by packing “laps” all around the abdomen, starting with right upper quadrant around the liver, then around the spleen and in the lower abdomen.
The money is on the liver. At least I don’t see a lot of active bleeding.
I pulled the packs from the lower abdomen. This area was pristine, no active bleeding, no hematoma. Next I “ran the bowel” which means I checked the small bowel from its beginning at the Ligament of Treitz until it terminated in the cecum. No injury. The packs were pulled from around the spleen. The left upper quadrant was also spotless; without bleeding or injury.
Time to work.
I gingerly removed the packs from around the liver. There was adherent clot over most of the right lobe with a laceration into the parenchyma and a small amount of oozing of red blood. The capsule of the liver had been disrupted over most of the right lobe.
Maybe just leave a drain? No, he’s been bleeding. I definitely need to do something.
I left the clotted blood which coated the denuded liver surface in place and approached the laceration. This was a crevice which ran from the superior right lobe laterally and inferiorly. Bright red blood was slowly welling up and then running down the liver’s surface. Carefully, carefully I put my hand behind the liver and gingerly lifted the right lobe, this brought the laceration closer to me so that I could actually see what I was doing. I packed laps behind the liver which helped hold it in place. I divided the right triangular ligament, which is a peritoneal attachment holding the right lobe. This allowed me to bring the laceration even closer. Now I could see into the depths of the liver, clean out the clot under direct vision, find what was bleeding and stop it,
I hope.
I began by washing away the clot, irrigating it with saline, doing my best to cause as little disturbance as possible so as not to stir up new bleeding.
What’s happening?
My thoughts preceded my words.
“Is there a problem?” I asked the anesthesiologist. “All of a sudden everything is bleeding.”
Indeed, the surface of the liver was now a continuous ooze of blood which was filling up the belly. The laceration was briskly filling up with bright red blood. The trickle had become a flood.
“Nothing’s changed…wait, how did that happen?” the anesthesiologist replied.
“How did what happen?” I inquired, a sense of urgency in my voice.
“His temp is 93.5. I’ve only given him 2 units of blood, but something has caused his temp to drop. I don’t know how long it will take to warm him.”
How did he get so cold? Maybe a transfusion reaction? Just pack him for now, get him warmed up and then come back and fix the problem.
The commotion at the head of the table faded away as I tuned out everything and concentrated on the problem at hand.
“Laps, a bunch of them,” I ordered, the level of my voice rising only slightly.
I packed laps into and around the lacerated liver, holding pressure and then packing more until they stayed dry.
I closed his belly quickly and we rolled him back to the ICU. His blood pressure was 100/60, heart rate 110, temp 93.7.
I rushed through the immediate post op tasks of dictation and orders and then went to face his worried family.
I found Mom and Dad in heated discussion.
“Would you believe it?” Mom stated as she turned to me. “Wonder man here has an insurance plan that doesn’t cover ‘animal related injuries.’ What kind of insurance is that?”
“One of the questions was about animal related activities,” he replied, a bit sheepishly. “I couldn’t lie.”
“That is not a concern at present,” I said. “Worry about that later. Right now I have some news for you. I guess you can tell that I’m out of surgery. We had a bit of a problem…”
“Jeremy’s OK isn’t he? He better be OK,” Mom almost threatened.
“He’s OK, at the moment, but as we were working he started bleeding more, bleeding from places that should not have bled. His blood wasn’t clotting. I did what I could do to control everything, but he’s still not out of the woods and I’m not a hundred per cent sure what the problem is.”
“How is he now?” Dad asked, his voice filled with nothing but anxiety and worry.
“He’s stable, blood pressure is normal, all his organs seem to be functioning. It looks like his body temperature dropped and blood doesn’t clot well if you’re cold. We’re doing what we can to warm him and make sure there are no other clotting problems. I packed a bunch of surgical pads around the sites which were bleeding and that has controlled everything, at least for the moment. He will need to go back to surgery in about 48 hours to remove them. In the meantime we need to correct his temperature and any other abnormalities. And, hope he doesn’t bleed anymore.”
But, he did continue to bleed. Besides his low body temp, his coagulation studies were abnormal. Most likely everything was intertwined. Blood clotting is a complicated series of events which starts with platelets plugging a hole in a blood vessel, followed by a cascade of enzymatic reactions which lead to a mature clot. Biochemistry teaches us that such reactions work best at normal body temperature. Significant lowering of body temperature causes derangement of normal clotting. And, once a body starts oozing it tends to beget more oozing, sometimes leading to the flood I witnessed within Jeremy’s belly. Thus, my decision to pack around the site of bleeding and stem the tide for the moment. This action, I hoped, would buy time to correct the underlying problem.
It worked, at first. I checked his coagulation status. His PT was elevated at 22 and his PTT was 48. His platelets were OK at 110,000. The nurses were working on warming his with a heating blanket and warmed fluids. He was transfused two jumbo units of FFP, plasma which would replace the clotting factors which had been consumed.
Maybe he’s out of the woods.
But, eight hours later, at four in the morning, his heart rate started to rise, his blood pressure dipped and his hemoglobin dropped from 10 to 8. There were a few bright spots. His body temperature was normal and his PT was down to 17 and PTT was normal.
“Transfuse two units PRBC’s and give another jumbo unit of FFP,” I ordered. “I’ll be in to see him.”
What to do? What to do? There must be some blood vessel which continues to bleed. Should I operate again? I’ve already been there. Maybe, maybe there’s a better alternative? Yes,  there is another alternative which might work. I hope Dr. L. is on call.
My plan was simple. Rather than dig through the injured liver looking for the source of bleeding, the problem would be approached from a different angle.
“I know you don’t like to get up early, but I really need your help,” I explained to Dr. L. I told him the whole story.
“Do you think you can do an arteriogram and embolize whatever hepatic artery is bleeding?” I finally requested.
“It might work,” he concluded, “although I’ve never embolized for this type of injury before.”
It was true. Angiography and embolization of arteries for trauma is commonplace these days, 25 years ago such a practice was sporadic.
I called Jeremy’s Mom and Dad and explained his condition and the plan.
An hour later he was wheeled down to the angiography suite.
I stretched out on the couch in the doctor’s lounge.
Maybe I should go home and sleep for a couple of hours. With my luck I’ll get called back as soon as I walk in the door.
I closed my eyes for a few minutes, until I was interrupted by a call from Dr. L.
“There was a tiny blush from a branch of the right hepatic artery. I did a subselective embolization of the right hepatic. I think he’ll be better,” Dr. L. reported.
“Thank you,” was all I said.
Six thirty. I guess I’ll make rounds and then check on Jeremy.
Jeremy did stabilize. His heart rate came down to 95, BP stayed around 110/60, he was awake and alert, talking, wanting to eat.
“Clear liquids for now and we need to take you back to surgery tomorrow to remove all those packs,” I reminded him and his parents.
I scheduled the next procedure for the next day to be done around 4 pm. Unfortunately, I was on call and had to deal with a perforated ulcer before tackling Jeremy. It was around 7 pm when the OR crew came to pick him up.
“I’ll be out to talk to you as soon as I’m done I reassured Mom and Dad and a multitude of other relatives and friends.
“Could you talk to another doctor on the phone” Mom asked.
Really, do I have to?
“Another relative?” I asked, a bit facetiously.
“It’s Dr. Red Duke,” she added.
“Oh, OK.”
Dr. Red Duke was a local celebrity. He was a general surgeon at the Texas Medical Center, was regularly featured on local news shows where he would explain a variety of medical and surgical maladies and what to do about them. Outside of that I really didn’t know him.
“Hello, this is Dr. G.”
“This is Dr. Red Duke,” he answered in his thick Texas drawl. “Tell me what you’re dealin’ with thar, young fella.”
I presented the case as succinctly as I could and he listened without interruption.
“Sounds like you’ve done a fine job, doctor. My only advice is that when you remove those lap pads, soak them in peroxide first. If you do that, they won’t stick and you won’t stir up any new bleeding. Good Luck.”
“Thank you, now I think they’re waiting for me.”
I hung up and headed to the OR where they really were waiting on me.
“Sorry to keep you waiting,” I explained, “but I had to get some advice from Dr. Duke.”
“You mean Red Duke.”
“Sho ‘nuff,” I answered in my best Texas accent, “the family called him. Now let’s get this done with.”
This return to OR was most uneventful. There was only a couple hundred cc’s of old dark blood, the packs easily came out after soaking them with saline and there was no bleeding. The abdomen was washed out, I left a drain by the liver and closed him up.
Maybe I can get a full night’s sleep.
No such luck. I was in bed by ten, but at 1:00 the phone rang.
“Jeremy is very short of breath. He’s breathing at about 36 (normal 12-16), his oxygen saturation is 90% on 100% nonrebreather, heart rate is 120, BP is high at 150/95.”
“I’ll be in to see him.”
I’m getting tired of this.
For the third night in a row I climbed out of bed and made the twenty minute drive to the hospital.
Jeremy was sitting upright in bed, his oxygen mask in place, breathing at a rate of about twenty eight.
“What’s going on, Jeremy?” I began. “Any pain?”
“Just feel winded, like I can’t get enough air into my lungs.”
His oxygen saturation was at 91%, heart rate was 120. BP, urine output were OK. His chest X-ray looked a bit congested and there were bilateral pleural effusions, which means fluid around his lungs.
“Do you think we need to intubate him, Dr. G?” the ICU nurse asked.
“Give him some Lasix, 40 mg, now. I’m going to talk to Pulmonary.”
I called Dr. P. and told him the story, while Jeremy got the Lasix.
“Dr. P. will be in,” I told the nurse, but I could already see improvement with the Lasix.
Jeremy put out about 4 liters of urine. His breathing calmed and he began a steady improvement. His bilirubin rose to about 6, possibly related to the embolization of his liver, but then came down to normal.
There was no more bleeding, no respiratory difficulty, he was soon up walking and eating and he went home about twelve days after the original injury.
The control of bleeding utilizing angiography and embolization was a technique I had used prior to Jeremy, primarily for bleeding secondary to pelvic fractures and bleeding from tumors which could not be accessed surgically. The technique now is more common, often being used for trauma to the spleen, as well as liver and the aforementioned pelvic fractures. It is a true life saver in those cases where the patient has an isolated injury to an organ which will tolerate the embolization.
The liver has a dual blood supply, receiving blood from the hepatic artery and the portal vein. In this case, embolization of the artery did the trick.
I saw Jeremy about four years later. He came to see me because he thought he had a hernia. He had given up riding in the rodeo and was working locally as an electrician. He did not have a hernia.
His Dad paid me ten dollars a month for a couple of years, determined to make up for the lack of insurance. I told my office staff to write off the balance and forgive the rest of his debt after about two years.
I stay away from horses, except for the occasional trips to the race track.