Across The Red Line: Stories From The Surgical Life

1. M & M

1 M & M “Did you split the sternum?” asks Dr. Stack, the attending trauma surgeon. He wants to know if the operative team opened the breastbone in order to gain access to the heart. “Yes,” responds the fifth-year resident. He is the chief resident on the Trauma Service and this is his last year of training. It’s Monday, 7:30 A.M. We’re at M & M. It means Morbidity and Mortality Conference. Once a week the entire surgery department gathers together in a lecture hall at the medical school. The purpose: to discuss each error, each complication, each bad result and every death that has occurred in the last week on all of the university teaching services. There are several teaching services. At the big municipal hospital the University oversees the cardiovascular , trauma, pediatrics, transplant service, and two elective surgical services. And there are several services at the VA Hospital and one at the cancer center. Almost all the residents and “attending” surgical faculty are here—about 65 surgeons and surgeons-in-training in all. Right now the trauma chief resident is in the pit, facing up at tiered auditorium seats that hold his inquisitors. His job is to describe the case, tell what went wrong, and respond to staccato bursts of questions coming from the faculty. He’s learning to think on his feet, a skill that he will find useful at the operating table and at the bedside. 13 I glance at the Xeroxed sheets in my hand. The first two pages have short descriptions of the complications (morbidity ) and deaths (mortality). Behind that there are ten pages listing every operation done by members of the department during the past week. The case under review is described as: 24 y.o.w.m. unrestrained MVA hemoperitoneum, exploratory laparotomy, right hepatectomy, hypothermia, hypotension, coagulopathy, packs, expired in RR. So that’s the gist of it. From the sheet I learn that this 24year -old white male was in an automobile accident (MVA —motor vehicle accident) and he was not wearing a seat belt (it is amazing how common that is). He had a distended abdomen when brought to the emergency room. It was immediately recognized that the abdomen was full of blood (hemoperitoneum). He was taken to the operating room, anesthetized and his abdomen was opened and explored (exploratory laparotomy). I can imagine the scene; blood filling the abdomen, the surgeons scooping it out with their hands and mopping it up with twelve-inch by twelve-inch pieces of cloth called lap pads. There’s a race going on. The surgeons must find the bleeding source and control it before the patient bleeds to death. But it is hard to see with all the blood in the way. Suckers are used to suck unclotted blood out of the abdomen, but some of the blood has clotted; this man’s body is trying to stop the leak, too. Wherever the blood is coming from, it is leaking out too fast to be occluded by clot. So the blood spills out into the abdomen, covers the intestines, the liver, the pancreas and clots there, futilely, too late. The horse is out of the barn. The clotted blood clogs the suckers and must be scooped out by the surgeons 14 Chapter One who put it in a big sterile wash basin that the scrub nurse holds right next to the wound, for they are all in a hurry. The sheet tells that the right lobe of the liver was removed (right hepatectomy) and that the patient got cold (hypothermia) first from lying at the accident site, then from the cool fluids administered to his veins in the ambulance , now from having his abdomen open. The open abdomen loses lots of heat by convection and this cooling must be reckoned with in all operations that open a body cavity. I know his blood pressure was perilously low (hypotension ) and that these factors and others caused the normal blood clotting mechanism to collapse (coagulopathy) and he was not clotting at all by the time the surgeons got there. And now I read that they packed the abdomen with gauze packs to stop the bleeding by tamponade and took him to the recovery room (RR) to warm him under hot blankets and lights with the hope that restoring his temperature to normal would restore his clotting. It is there that he expired. Despite...