27 January 2011

bad days

I'm coming to the conclusion that when choosing a specialty, you need to choose the one where even the bad days are somewhat fun. I don't mean bad as in the previous post where you're emotionally drained; I mean bad as in technically the sh*t is hitting the fan. An example of one of these painful days...

I got to the unit at 5:30am for pre-rounds, as usual. I checked in on my patients and took down the dressings, as usual. We rounded as a team and I re-dressed the wounds, as usual. There was no morning conference so I headed down to the OR early to put in the patient's Foley and watch anesthesia place the central lines. The planned surgery was an open (cut the abdomen open, rather than inserting a catheter though the vessels) abdominal aortic aneurysm repair. It should take 4-5 hours. I was scrubbing with the uptight fellow and one of the old Spaniards.

The case began and he was a little wetter (oozing blood) than expected, but otherwise the dissection to the retroperitoneum was uneventful. We were able to clamp infra-renally (good) and got proximal and distal control of the arteries near our anastamosis sites. We began grafting to the aorta, but the clamp appeared through the posterior wall. This means the aorta had torn, so we had to reclamp, higher, and get control of the bleeding. We managed to get the graft on, but the patient was still bleeding. We discovered the aorta had torn proximal to the clamp. We attempted to mobilize the aorta and sew the tear closed, but it continued extending. It look 3-4 hours and a supra-renal clamp to repair the tear. We turned our attention to the iliac anastamoses, and one of these also proved problematic with excess bleeding. We finally closed the belly to find he had stopped urinating and had stooled all over the OR table. At this point he had lost just over 13L of blood.

We did dopplers of his feet to check for pulses and found one limb to have absent pulses and pallor. We prepped for a thrombectomy, to extract the presumed clot released when we came off the aortic clamp. Once in his groin, we found very calcified arteries and insufficient forward flow to float a catheter down the leg. We immediately converted to a femoral to femoral bypass graft. We opened the other groin and reheparinised him. The bypass was completed uneventfully and his groins were closed. At this point, he had another 2L of blood loss.

The whole operation took 14 hours (I was allowed to leave at hour 12) and ended up being really rough on his kidneys (suprarenal clamp) and having a very long aortic clamp time (no fresh blood to the legs -> tissue loss -> also bad for kidneys). He's stable (for now) in the ICU. The point (long-winded, yes) is that this was a tough case where everything was going wrong. This is a painful surgery, even for a surgeon. In fact, the attending that started the case was not the one who finished it. If you can still find some fun in this kind of day, then maybe the OR is the place for you. Me, well, I did not find so much fun in this. But there are rough days in the ICU I get some rush from. Where the fight is energizing as well as draining. So I don't think I'm a future surgeon, but I think I earned some respect from them for standing in that OR for 12 hours with no food/water/peeing/sitting.

No comments: