“Any surgeon to OR 6 STAT. Any surgeon to OR 6 STAT.”
No surgeon wants to hear or respond to a call like that. It means someone is in deep kimchee and needs help right away.
I was in the locker room, just about to strip off my scrubs and dress to go out with my wife for the evening. We had finished a full day of routine surgery—two gallbladders and a colon resection—and had plans for dinner. Our older son was home from college and had offered to watch his younger brother for us.
I closed my locker and walked back out to the OR control desk. Michele, my wife and first assistant, was already there. A glance at the control board showed me that Dr. S was in room 6. She was a gynecologist, and according to the board, was doing a routine diagnostic laparoscopy. The bustle of technicians and nurses running in and out of the room indicated that it was anything but routine.
We made our way to the room, and I stuck my head in. My friend Jon was the anesthesiologist. He was squeezing a bag of packed red blood cells to make them run into the IV faster.
“We could use some help,” he said, calmly as ever. But he rolled his eyes toward the table.
Dr S. stood there, blood coating her arms and chest, her eyes looking at me but somehow also looking far away, the thousand yard stare of someone out of their depth and very afraid.
“Hey, Lou,” I said, using her first name as I stepped into the room. Michele followed me and began speaking quietly to the circulating nurse.
“What’s going on?” I asked as I looked over her shoulder.
The patient’s abdomen was open and Lou had her hand deep inside. The abdomen was full of blood, but it didn’t seem to be increasing in volume. Whatever was bleeding, Lou seemed to have controlled it by putting her hand in.
“I think I hit a big vessel with my initial trocar,” she said, referring to the hollow tube that was used to introduce a laparoscope into the abdomen.
The initial insertion is always blind, and there’s a risk that the sharp tip of the introducer may hit bowel or blood vessels. The first thing a surgeon does on looking in with the scope is to make sure there hasn’t been an inadvertent injury. Lou had seen blood rapidly filling the abdomen and had made a bigger incision right away.
“Is it mesenteric or retroperitoneal,” I asked, keeping my voice calm and matter of fact.
“I can’t tell. The belly is full of blood. I’m pushing down on the hole I made but don’t know what’s bleeding.”
I had an idea of what she had injured, and it made my heart rate bump up a tic. I didn’t say anything and forced some calm into my voice as I turned to the circulator. “We’ll need the vascular instruments, a Buchwalter retractor and some vascular suture, 3-0 and 4-0.”
The circulating nurse was already heading for the door. Michele nodded to me. “Already ordered. I asked them to pull a bowel tray, too. Just in case.”
I love my wife for a lot of reasons. Her coolness in a crisis is just one of them. She went to start scrubbing. I turned to Jon.
“Massive transfusion protocol?”
“Already called,” he said. “First cooler in five minutes.”
“I’m going to scrub,” I told Lou. “Just hold pressure and let Jon catch up.” She nodded, visibly calmer.
There’s an art to coming in to help a colleague in trouble. Most of us have been in that situation, both giving and receiving help. A scheduled case that goes bad is different from a trauma. In trauma, you expect the worst. Your thinking and expectations are already looking for trouble. In a routine case, trouble is an unwelcome surprise, and even an experienced surgeon may have difficulty shifting from routine to crisis mode.
The first thing to remember when stepping into a bad situation is that you are the cavalry. You didn’t create the situation, and recriminations and blame have no place in the room. You need to be the calm center to a storm that started before you got involved. Sometimes that’s all that is needed. A fresh perspective, a few focused questions, and the operating surgeon can calm down and get back on track.
Other times you need to intervene directly. This is harder to do in a way that doesn’t seem confrontational or condescending. The operating surgeon may be out of his or her depth, but this is still their patient. You are the consultant. You need to offer your service with respect, but not shrink from taking action if the patient is truly at risk. Lou had asked for help and was clearly relieved that we were there.
We finished the scrub and gowned up. The monitors showed that the blood and Lou’s holding pressure had helped. The patient’s pulse was slower, and the blood pressure, though still low, was stable.
I extended Lou’s incision as she continued to hold pressure. Michele, meanwhile set up the Buchwalter, a self-retaining retractor that freed up the assistant’s hands by keeping the abdominal wall open. I could see where the bleeding was coming from, much slower but still welling up from the retroperitoneum—the area behind the intestine near the backbone.
With Michele helping to retract, I opened the space above Lou’s hand and got my fingers around the aorta. I told Lou to release her pressure. Blood gushed up until I pushed down on the aorta. The bleeding slowed to a steady ooze. Lou retracted the root of the bowel aside and exposed the hole her trocar had made. It had punctured the anterior wall of the aorta. The hole was still bleeding slowly from blood back filling the vessel from collaterals. Now that I could see it, I put my finger directly in the hole and released the pressure from above. We now had control of the active bleeding. With Michele and Lou’s help, I dissected out the aorta above and below the hole and got vascular clamps on. The hole was about a centimeter in diameter, clean edged, and easy to repair. We let some blood back bleed to flush out any clots, and then fixed it with some of the vascular suture.
Once we were done and the patient stable, I asked Lou, “Do you want me to stay and help close?”
The acute crisis was over, the patient was stable and I was offering Lou a chance to take back control of the operation. It was more than just letting her save face. It reestablished the doctor-patient relationship she had begun when she first saw the patient. It confirmed for her and the rest of the room that this was still her patient, her case.
“No, I’m OK. Will you write orders for the ICU?”
“Of course.”
Michele volunteered to stay and help close the abdomen and I went to take care of the orders.
The patient recovered after a brief stay in the ICU and went home in less than a week.
The point of the story is that sometimes everyone gets in over his or her head. It has happened to me and will again some day. The primary role of the surgeon called upon for help is to not inflame the situation more. Everyone in that operating room is already having a very bad day. Your job, if you respond to such a call, is to get the operation back on track so the patient can be stabilized and the damage repaired. Then you need to back off and acknowledge that the primary responsibility has been returned to the original team.
We never did make it to dinner. My wife often jokes, “You take me to the nicest places,” but she knows how much I appreciate her when the crap hits the fan.
Bruce Davis, MD, is a Mesa AZ based general and trauma surgeon. He finished medical school at the University of Illinois College of Medicine in Chicago way back in the 1970’s and did his surgical residency at Bethesda Naval Hospital. After 14 years on active duty that included overseas duty with the Seabees, time on large grey boats and a tour with the Marines during the First Gulf War, he went into private practice near Phoenix. He is part of that dying breed of dinosaurs, the solo general surgeon. He also is a writer of science fiction novels. His works include the YA novel Queen Mab Courtesy, published by CWG press (and recently reissued by AKW Books as the e-book Blanktown). Also published through AKW Books are his military science fiction novel That Which Is Human and the Profit Logbook series, including Glowgems For Profit and Thieves Profit.
The Website: www.thatwhichishuman.com
The Blog: www.dancingintheor.wordpress.com
