Thursday, January 29, 2009

Case #4: Lord, Please Make It Stop Bleeding. (Case Reports from Kijabe Hospital)

Warning: This post is one of a series that describes a patient (case) that I have taken care of in Kijabe hospital, and it may contain graphic descriptions or photos of medical pathology written primarily for clinicians. For my non-clinical readers, use discretion before reading, and please excuse the medical jargon.

This is a case from November, only a couple of weeks after I took over my own surgical service.
While the perception on television is that the operating room is a stressful place to work, in reality, most surgery is quite routine, and there is only the occasional tense moment. However, every now and then, there is a case that really gets out of control and tests ones ability to cope with adversity…

***

“Hey, you wanna do a splenectomy for me?”

That was the question my colleague asked me in passing one day on a busy afternoon in the operating theater. The interesting thing about being “in practice” here in Kijabe, is that I didn’t have to wait long to get good cases. The other two surgeons are quite busy and willingly pass along interesting cases to me, and I am more than happy to take a few “general surgery” cases off their hands.  So I did not think I was being set up when my colleague asked me to do a splenectomy for him (nor do I think he knew the case was going to be as difficult as it was), but this innocent request to do a splenectomy turned into one of the most challenging operative experiences of my young career.

JM is a 28 yo man with a diagnosis of hairy cell leukemia.  While the appropriate treatment for his leukemia is chemotherapy, he had been having difficulty getting seen in the government hospital with his problem.  We do not have chemotherapy in our rural hospital formulary, but we do often take care of cancer patients who might need a major operation.  JM had developed splenomegaly (enlarged spleen), and the hematologic derangements that accompany this condition, namely profound thrombocytopenia (low platelets). Given his platelet level, the medical service thought a splenectomy might help stabilize him until he could get chemotherapy. Unfortunately, this would mean operating on a very large spleen with very few native platelets, (but we are able to give whole blood, and if it is less than seven days old, the platelets in the transfusion are still functional).

When I got to the operating room, and was able to palpate his abdomen and feel his spleen, I was impressed. His entire left abdomen down to the pelvis was spleen.  The anterior aspect of the spleen stuck out though his otherwise small abdomen.  I began to realize that his case might be more difficult than anticipated.  However, I had only been an independent attending surgeon for a few weeks at this time, and believed I could get the spleen out safely by adhering to the principles I had learned about general surgery and doing a splenectomy during residency.  After prepping, draping, and praying, I made an upper midline incision, and soon had access to the peritoneum. The spleen was bigger than any I had ever seen. I examined the abdomen, and pondered my approach.
 
There are two general approaches to doing a splenectomy. One is to divide the gastro-colic ligament and march along, dividing the short gastric vessels. This gives you access to the lesser sac, where you can try to find and ligate the splenic artery. The advantage to this technique is that you interrupt most of the blood supply to the spleen, and allow it to exsanguinate, making any subsequent dissection less bloody. Also, you are able to keep more of the blood in the patient instead of in the specimen. The disadvantage of this technique is that the splenic artery is often found way in a deep hole in the LUQ that is difficult to dissect safely. If an error is made, it is very difficult to control a large rent in a hilar vessel in a deep dark hole.  The other approach is to mobilize the spleen from its attachments and deliver the spleen out of the abdomen thus pulling the hilum out of the abdomen, and into easy access for division. This is the typical approach for traumatic splenectomy and also what one might do if an iatrogenic injury caused one to have to do a rapid splenectomy to stop bleeding.

I decided that I would try to get control of the slpenic artery first, as often in these cases of splenomegaly, the hilum has been displaced downward, and the splenic artery becomes tortuous and displaced inferior and anterior out of the posterior LUQ, and is thus easy to ligate. I got access to the lesser sac, and soon realized that this would not be an easy proposition. I could palpate the splenic artery, but it was very far away, and had not been displaced into an accessible position to ligate. Furthermore, the sheer size of the spleen, had left little room in the abdomen to work, and retract to see vital structures. I was still not worried. I knew how to mobilize the spleen, so I thought I would try the second approach, and deliver it into the wound. That’s when trouble really began.

I was able to deliver the lower pole of the spleen partially out of the abdomen. I began taking down adhesions and attachments. Unfortunately, the capsule tore a bit and started to bleed. No problem, I thought. Just pack that area, and go somewhere new. I went to the superior aspect of the spleen to try to take down the spleno-phrenic attachments, but just retracting here, caused some heavy oozing. I thought that unusual, and tried to see what was going on. The medial upper pole of the spleen was densely adherent to the left lateral segment of the liver, and this new bleeding was from the torn liver capsule. Now I was starting to sweat. I packed this area, and went to the superior lateral aspect of the spleen. Once again, I made very little progress before getting into substantial bleeding. I packed this area, and decided that maybe I should return to the hilum, and try to find that splenic artery after all…wrong move, some delicate hilar veins tore, and unleashed the worst bleeding yet.  I packed the hilum.  Now if you are keeping count, the spleen was packed on every side at this point, and I had already lost more than 500 cc of blood (that did not seem to clot very well). I thought about backing out, but knew I would have to leave the packs in and come back the next day, which did not seem like a feasible solution especially since the packs were only slowing the bleeding .

 
Me trying to deliver the spleen out of the abdomen


A close-up view of the "beast"


I swallowed hard, and decided, I was going to have to just accept some heavy bleeding, and get that spleen mobilized. I warned the nurse anesthetist about what was coming so she could get some blood, and proceeded to mobilize the spleen. The next 10 minutes were the most uncomfortable I had ever felt in the operating room. I started by just sharply taking down the adhesions between the spleen and the left lateral segment of the liver. The bleeding was impressive! Next, I got the inferior aspect of the spleen totally mobilized from the colon and kidney. By this time, the blood loss was so brisk that I began to feel that I was certainly going to lose the patient. I still had the superior-lateral aspect of the spleen attached to the diaphragm and LUQ retroperitoneum. Close to a liter of blood had just poured out, and I began to feel defeated. Difficult cases don’t usually do this to me. I may become frustrated for a moment, but I always say to myself, “Come on! Focus…and fix the problem”. But the bleeding and the circumstances became so overwhelming, that I found myself losing hope that I could get the patient through the operation.  

It was at that moment that I did something unusual for me. I usually pray before an operation as a matter of routine, but rarely do I pray during the case, at least not in earnest. But today, in that moment of hopelessness, I stopped for about 5 seconds, closed my eyes, and said, “I don’t think I can do this God. I need your help. Lord, please make it stop bleeding.”

I immediately became calm, I went back to work, and though it seemed that blood was just pouring out, I suddenly could feel a plane behind the spleen, and with a couple of bold cuts with the scissors, I managed to get the last part of the spleen free, and was able to deliver the spleen into the wound. Now I had the spleen on an easily controllable pedicle. I was able to quickly ligate the hilar vessels, and pass that sinister specimen off to the scrub tech. I then packed the LUQ, and systematically found all the small bleeders, and got complete hemostasis.

All totaled, the official stats were 2.5 Liters of blood loss, but I think it was closer to 4, and it was a rapid loss, especially for an elective case. I think I broke the Kijabe record for most packs (lap pads) used in a case: 65. (The final path report had the spleen at close to 5kg…which is 25 times the size of a normal healthy adult spleen.) As I closed the abdomen, and the patient stabilized with IV fluids and blood, I thanked God. The patient who I had thought was going to arrest on the table from hemorrhage, not only survived the operation, but he did well subsequently. The patient was sent to the “ICU” overnight, and did beautifully, and was eventually discharged to home on POD#6 with a referral for his chemo appointment in 3 weeks.  Amazing.

Since that moment early in my time as an attending, I have found myself praying during an operation on numerous occasions. It’s possible to get overwhelmed during a difficult case, but I have learned that prayer reminds me who is ultimately in control, and allows me to operate during the most daunting of moments as if only a trickle of blood had been lost. Not to say that I don’t still sweat in the operating room (especially since I am operating in the tropics without any air-conditioning), because I still have difficult moments during surgery. But I realize that I am trained to do this, and all I can do is my best, and allow God to do the rest. Once I see it from that perspective, I am able to face even the most desperate situations calmly and effectively with my mind and heart knowing who is really in control.
And you know what? The outcome is usually okay.

Learning to be EVER dependent on Him,
chad

“Oh what peace we often forfeit, oh what needless pains we bear…All because we do not carry everything to God in prayer.”
~Joseph Scriven from the hymn: What A Friend We Have in Jesus

4 Comments:

At Wed Feb 04, 02:46:00 PM, Blogger Pat said...

Wow, what a story Chad. Thanks for sharing this, for telling it so clearly and personally, and for all of your thoughtful insights throughout this blog.

Look forward to reading more, and possibly catching up in person when you get back to Boston.

Kind regards,
Pat Lee

Clinical Mentor, Partners In Health
Hospitalist Physician, Newton-Welleseley Hospital
Clinical Instructor in Medicine, Harvard Medical School

 
At Fri Feb 13, 07:15:00 AM, Blogger Mr. Wilson said...

Chad:

I know I should not be impressed by anything you do since I know you better than maybe anyone else, but reading these medical cases is truly amazing to me. I think the most moving part is how you confront fear, the grave consequences of mistakes...

I am so proud...

okay...enough mush...back to work...

 
At Mon Oct 27, 10:14:00 AM, Anonymous Anonymous said...

Hi doc,
Are you still at Kijabe.I have a spleen condition and I feel God leading me to seek assistance there...would love to have you look at it...

 
At Mon Oct 27, 10:20:00 AM, Anonymous gracie said...

Hi doc,
Are you still at Kijabe.I have a spleen condition and I feel God leading me to seek assistance there...would love to have you look at it...

 

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