End of the evening feeling exhausted from a very busy day, taking a breather at the desk pondering if I snuck out right now if anyone would notice. When I get a call from charge, we have an add on, sigh, I will meet you at the board. Arriving to charge I am told general surgery has a perforated colon. Okay, well general surgery is one of my favorites other than vascular, so I go to the core to begin to collect my items. The scrub techs left at this point in the evening are typically in ortho, so I can sense the anxiety in their voices, offering comfort that we will get through it.
Gathering the information in the history and physical to attempt to decipher how sick this patient is, they appear to be very ill. Multiple compounding problems, each of which can be life threatening in their own realm. Reviewing their labs, seeing that the patient is septic, also having a low hemoglobin, I begin to prepare myself to ensure we have an active type and screen in the blood bank. After getting setup I walk up to the desk to inquire if the surgeon is here, and in walks Dr. D, “I’m ready, I really don’t want to do this surgery, but family asked to try everything.” I sigh, that is just the wrong omen to have before this case.
Getting the patient, she is very weak, you can see the pain in her eyes with every bump the stretcher hits on the stroll back to the room. We place the backboard under her, and get her onto the bed. We do a rapid sequence intubation considering the amount of things left in her stomach that could leave her at higher risk for aspiration pneumonia at induction. In walks Dr. D, he preps the patient, which I love him for, because then I can focus on my duties, and if it’s wrong, it’s on him.
Draping, and then scalpel, incision, dissection down begins, cutting down, then I hear “I need vascular now”. Racing to the desk, I tell charge to call vascular into OR 5 now. Running back through the core gathering all vascular supplies I know we may need, hemoclips, vessel loops, kitners, vascular instruments, gown, gloves, doppler and race back into the room. I can see the panic in Dr. D’s eyes, that something has happened, and he knows he needs help to fix it. Asking for clamps, applying them, while trying to suction up blood to attempt to visualize what has happened. Lap sponges going in by the second to attempt to move and absorb what is spilling into the field.
Vascular surgery arrives, and scrubs in adjacent to Dr. D. Evaluating the situation and assessing what can be done to repair it in the heat of the moment. My attention is then brought to the head of the bed, where anesthesia is now struggling with vital signs. Her blood pressure is dropping, fluid resuscitation is only slightly working, they are using a port in her chest for one line of fluids, and started a peripheral IV in her arm. They place an arterial line to monitor her blood pressure closer, as I assist in gathering the supplies. Heart rate is rising, her body is trying to do what it can to save itself. As the blood pressure drops, the heart rate is beating faster and faster, as the anesthesia provider is processing all components second by second making split second decisions on what to give to stabilize the patient.
Vascular identifies the issue, at which point he requests anesthesia to heparinize the patient so he can attempt to repair the torn aorta bifemoral graft. Anesthesia gives heparin, and I call for a I-stat to begin to monitor the level of thinness for vascular. Vascular is working frantically to repair the torn graft, Dr D standing back trying to offer assistance, but I’m sure disappointed in himself that he didn’t see it in the patients history. Vascular begins requesting for more blood thinner, clots are forming, he can’t get the graft repaired, and as the blood thickens the risk of clots throwing and killing other appendages is growing.
Vascular finally gets graft repaired but is concerned regarding the amount of clots that have began to form. Breaks scrubs and requests doppler, I approach the bed to assist him in assessing pulses in the feet, when he raises the drape, the right leg is white, no pulse. I immediately grab what I can to begin a cut down on the right leg. Dr D is closing up top, and we will now begin a cut down on the femoral artery in an attempt to save the leg. Anesthesia is scrambling up top, confused as to why the blood thinning level hasn’t changed. When they realized the IV they were using to give the Heparin in, was infiltrated (not in the vein).
Vascular scrubs back in after we collect the drapes and items he will need. Completing a cut down in record speed, especially after the patient is properly heparinized. Restoring pulses to the foot and marking them with x’s for PACU to watch as the patient is in recovery. Pulling down the drapes, the patient looks absolutely terrible. Thinking to myself was this even worth it? This lady may have died from her perforation, but she would have died surround by her family, and with her mind intact to enjoy those moments.
Are we making the right decisions here? Allowing family members to push for everything to be done despite knowing the likelihood of it giving the patient a good outcome is minimal. Dr D knew in his heart that this surgery wasn’t going to go well, his body and mind telling him not to do it but allowing himself to be convinced by the family to try. Now Dr D may struggle with that choice and/or death later. The patient made it to recovery, and coded and died within minutes. We tried everything, it wasn’t worth It in my heart.