Weekend So Far My first two nights at work this weekend have been busy ones. Thursday night I did a case involving a 55 year old man. He had been relatively healthy until he started having lower back pain recently. On Thursday he had sudden onset of loss of sensation in his legs, leg weakness, and loss of control of his bladder. A CAT scan revealed a mass on his lower spine that was impinging on his spinal cord. He was brought to the operating room in an attempt to decompress his spinal cord to hopefully restore normal function. After I got the patient to sleep he was turned face down on the operating table and the surgeons got to work. The surgeons worked on the patient for about 6 hours. The mass turned out to be very vascular and therefore the patient lost 3500 mililiters of blood during the proceedure. I gave him 8 units of blood products to replace this loss. I left the breathing tube in at the end of the case. It will be several days before the surgeons will be able to tell if the patients spinal cord was permanantly damaged. The patient will need a followup surgery in several days to stabilize his spine and possibly need chemo/radiation if the pathology on the mass shows that it was cancerous. Last night I spent the whole night in the operating room. We did kidney transplants on two different patients. Both case went smoothly. Two more nights to go.

Back to Work I haven't blogged again for a while. I was off for several weeks and then last weekend was much quieter than average. In four nights at work I only did two cases both of which were short and routine. This weekend as been much busier. On Friday night my student and I started things off by taking over a case involving a 45 year old man. He was a prisoner who had been stabbed multiple times by another inmate. He had wounds to the abdomen and chest. The surgeons were able to stop bleeding in his chest and the abdominal wounds were superficial. We left the breathing tube in at the end of the case. Our last case of the night was a sad one. A 16 year boy had suffered a fractured neck playing football. He already had a breathing tube in place before he came to the operating room. We were told that he had spinal cord damage and could not move his legs before the case. He still had use of his arms and the purpose of the surgery was to stabilize his neck to maintain the use of his arms. In this case the surgeons started out working on the front side of his neck. Half way through we carefully turned the patient onto his stomach and the surgeons worked on the back side of his neck. The breathing tube was left in at the end of the case. It will be several days before we will know how much use of his arms the young man will still have. Last night my student and I did the anesthesia for two patients who were receiving kidney transplants. These are happy cases for the patients who will not have to get dialysis three times a week as they had been. One more night to go.

When Plastic Surgery Goes Very Wrong I haven't blogged for awhile again I see. I could make excuses about not doing much in the way of interesting cases lately, which is true, but mostly I guess I am just a little bit lazy. Tonight however I did a very sad case of plastic surgery gone wrong. Five days ago at another hospital a 45 year old woman went in for what was supposed to be liposuction of her abdomen. When a plastic surgeon does liposuction the first thing they do is make multiple injections of a special solution just under the skin. For the abdomen this would mean 20 to 30 injections into the tissue just under the skin. This solution loosens up the skin and allows the surgeon to then insert a pencil sized suction device under the skin and suck out the excess fat. In this case the solution was injected to deeply. Instead of being just under the skin the solution was placed into the muscle of the abdominal wall causing it to loose its blood supply and get necrotic. Now five days later the patient was transferred to our hospital. She is very ill with a breathing tube in place and on IV medications to prevent her blood pressure from dropping. Our surgeons washed out her abdominal cavity but were unable to close up the abdomen due to massive swelling of her intestines. They said that it will require several more surgeries to be able to finally close her abdomen and she will have a large scar from the incision that starts below her belly button and goes up to just under her sternum. This poor women went in for a "routine liposuction". She got anything but routine.

Sad Ending to a Slow Weekend Finished another four nights at work. The first three nights were mostly quiet. Thursday night I finished the last hour of an eight hour brain tumor resection case. I left the breathing tube in at the end of the case and took the patient to the ICU. My only case for Friday night involved a 45 year old man with a torsioned testicle. His right testicle was twisted inside his scrotum. This is not only extremely painful but if the problem is not corrected within 4-6 hours the testicle can get necrotic and have to be permanently removed. In this case the surgeons were able to correct the problem in time. On Saturday night I did a case involving a 31 year old man. He had been assaulted and his jaw had been broken in 2 places. It took the surgeons 3 hours to repair the damage and the man's jaw will be wired shut for several weeks. Sunday night I did one very sad case. A 31 year old woman had been in a rollover car accident. Her right arm had massive damage. The tissue on the inside surface of her forearm from the elbow to the wrist was gone. Muscle, nerves and blood vessels were mostly gone and the bones were broken into multiple places. The surgeons worked for seven hours to repair blood vessels and the bones. They felt that there was a 95 percent chance that the woman would end up having the arm amputated within a few days. The truly sad part is that while we were working on her they were working on her 5 year old son in another operating room. We heard he had very similar injuries and would probably also loose an arm.

Fixed and Dilated This last weekend was a fairly typical one. My student and I did several cases. We did one involving a 20 something year old boy with a gunshot to his right abdomen. He had damage to his small intestine, his liver and his diaphragm. The surgeons were able to repair the damage. We also did a case of a 55 year old lady with a small bowel obstruction and the case of a fifteen year old who fell while rock climbing and injured his arm. We also did one very sad case. A 19 year old boy was brought up from the emergency room about 2 in the morning on Saturday night. We heard that he had been at a party where some sort of fight had broken out. The young man had been hit in the head with a baseball bat. He already had a breathing tube in place when they rushed him up to the operating room. It was then that I saw his eyes. His pupils were huge with almost none of the iris, the colored part of the eye, visible. When I shined a bright light in his eyes the pupils did not change. The medical term for this is that his pupils were "fixed and dilated." This is an extremely bad sign that means severe brain damage or brain death. The surgeons felt that severe swelling of the patients brain was causing the problems. If they could get his skull opened quickly and relieve the pressure there was a very small chance that he could at least partially recover. In the operating room the surgeons quickly cut open his scalp and with a special saw cut a 6 inch diameter circle through the patients skull. They lifted off the top of his skull which looked very similar to a Jewish yarmulke. This immediately gave the brain room to swell. The surgeons then worked on stopping the severe bleeding that was occurring from the brain. The surgeons stopped the bleeding. Normally when you look at a patients exposed brain it pulsates with small movements. This young mans brain did not move at all. The surgeons closed his scalp leaving the piece of bone they removed out. It will be replaced later if needed. At the end of the case the young mans eyes were still fixed and Dilated.

Good Weekend for My Student I had another student working with me this last weekend and he got to do several very good cases. On Saturday night a 59 year old man had suffered a minor stroke 2 days before. He had been doing well and seemed to be recovering. He had suddenly become unarousable and he breathing had become depressed. The neurosurgeons determined that the pressure in his brain had suddenly increased. To decrease the pressure they removed a piece of his skull about 4 inches in diameter. The piece of skull will be preserved in a special freezer at the hospital. In 7 to 10 days once the swelling in his brain goes back down the surgeons will replace the piece of skull. Shortly after finishing that case the neurosurgeons brought up a 60 year old women who was also suffering from a stroke. They removed a piece of her skull like they did in the first case and also stopped some bleeding. Both of these patients were taken to the ICU with their breathing tubes still in place. On Sunday night a 24 year old man was brought up with a stab wound to his left chest near his left nipple. His heart rate was high at around 140 beats per minute and his blood pressure was low. We quickly got him to sleep and the surgeons opened his chest. They split his sternum to get better access to his heart. He had a single stab wound to the right ventricle of his heart. Blood had filled the pericardium, the sack that surrounds the heart, compressing it. This compression makes it much more difficult for the heart to beat properly. The surgeons opened up the pericardium relieving the pressure and repaired the hole in the man's heart. We gave the patient several units of blood to replace what he had lost and left his breathing tube in place at the end of the case. he should make a complete recovery. A good weekend for my student.

No Such Thing as a Routine Case Thursday night at work I was asked to finish off a case that had already been going for about 7 hours. My student and I took over the case which was finished in about an hour. By the time we took over the case it was pretty much over and I would not normally blog about it. In this case the story is so sad, so scary that I felt I had to talk about it. On Thursday afternoon at a different hospital a 20 year old otherwise healthy man went in to an operating room to have his gallbladder removed. The case was going to be done laproscopically which is how most gallbladders are routinely removed. To do the case several laprascopic ports have to be put into place first. The ports are hollow tubes that are a little bigger around than a pencil. Once they are in place the surgeons can insert long thin instruments and a camera to see inside and do the work to remove the gallbladder. The ports themselves have to be carefully put in place. A very sharp tip is put through the port which is then inserted through the abdominal wall. Imagine a pencil with razor sharp tip being pushed through the abdominal wall. Great care must be used to be sure that the port gets through the abdominal wall but does not damage anything on the inside. Over the years I have seen several cases where internal damage was accidentally done by the surgeon as he/she was placing the ports. The damage has always been to the intestines, serious but usually not life threatening. Unfortunately the damage done in this case was much more serious. Somehow the surgeon at the other hospital hit the patients aorta while placing the laprascopic port. This caused massive bleeding as the aorta is the largest artery in the body. They opened the patients abdomen and got a clamp on the aorta to stop the bleeding saving the patients life. Unfortunately there was not a vascular surgeon at the other hospital who could repair the damage to the aorta. With the aorta clamped there was no blood flow going to anything in the lower half of the patients body. The patient was kept asleep, was packed up and was transported to the hospital where I work. By the time he arrived and our vascular surgeon was able to rush him to our operating room the aorta had already been clamped for several hours. Our vascular surgeon worked for hours on the patient. He repaired the damage to the aorta and then worked on the arteries and veins in his legs to remove blood clots that had formed during the hours the aorta was clamped. Unfortunately when my student and I took over the case late Thursday night the surgeons were completing the amputation at the knee of his right leg. We left him intubated and took him to the ICU. When I went in to work last night I got an update on the patients condition. That afternoon they returned him to the operating room to amputate the left leg just below the knee. His kidneys have been damaged though how badly is yet to be determined. He may end up impotent and unable to produce viable sperm so he may not be able to father any children. Finally he will still need to go back to the operating room in the near future to have his gallbladder removed. So much for a "routine" surgery.