Indexing Title: JMDEGUZMAN’s Medical Anecdotal Report [05-07] 

MAR Title: “In God’s Intervention”  

Date of Medical Observation: July 2005 

Narration:

            In the past few months I listened to the stories of my co-residents handling suicidal patients, giving these patients the chance of survival when they have renounced it once. As doctors we do not really have much choice, do we? Our calling to save lives runs through our veins and we could not care less for these psychologically disturbed persons. Hence, if put on the same situation I would do the same, perform what is expected of me, “try to save lives no matter who they may be or what they do”. I just never thought that it would happen to me in so short notice.

            A young lady, only in her sixteen, was brought in the emergency room semi-unconscious. She had four stab wounds, two in the neck and two in the abdomen. The one in the abdomen had omental evisceration indicating that it was penetrating. She was hypotensive, less than 80 systolic. The stab wounds in the neck were not bleeding, no expanding hematoma either. The one who brought her was also confused; she just stared to me blankly, unresponsive to my every query. The only words she could utter were “She did it to herself, she stabbed herself”. I could not believe it at first that this young lady could inflict to herself such fatal wounds but I let it aside, I will not argue with it. I had to address the current situation at hand - fast. I ordered the patient to be brought in to the operating room at once after inserting intravenous fluids fast drip. With all the first hand informations I had gathered, I decided to explore the abdomen to look for the source of bleeding. True enough, I noted three liters of hemoperitoneum with the source of bleeding coming from an injured infrarenal inferior vena cava. Fortunately, we were able to control the bleeders and proceeded with the repair of the vena cava and associated intestinal perforations. During the operation I noticed that the blood pressure never reaches above 90 systolic but stable between 80 and 90, we have good urine output and pulse oximeter indicated good oxygen saturation. These were fed to me by my anesthesiologist from my constant inquiries. Being wary also of the stab wounds in the neck, I informed my anesthesiologist to check on it from time to time and alert me if there were any external hemorrhages and/or bulging hematoma as I proceeded with the laparotomy. Much to my surprise and sigh of relief there were no such occurrences during the abdominal operation.

            After closing my laparotomy incision, the blood pressure improved to 90-100 systolic. Again checked for the nth time the stab wound in the neck and just I was about to conclude that it did not have any vascular injury, a sudden spurt of bright blood almost hit the ceiling of the operating room. I immediately put finger pressure on the area to somewhat occlude the bleeding whatever it may coming from. Luckily the patient was still intubated, I asked my anesthesiologist to re-anesthetize. I asked my assistant to do the finger pressure while I re-scrubbed to do the neck exploration. On neck exploration, we noted that the right common carotid artery just before its bifurcation had a thru and thru perforation. Again we were able to control and repair the injury. After the last stitch on skin closure, I silently prayed and thanked God for giving me the time to be in both places, directing my decision making, and assisting my anesthesiologist in making the patient in unintentional state of controlled hypotension during my exploratory laparotomy.

Insights: (Discovery, Stimulus, Reinforcements) (Physical, Psychosocial, Ethical)

            Permissive hypotension in trauma resuscitation has been widely proven in experimental studies and some claimed of using the process in actual practice with positive results. The principle was to maintain the blood pressure at 80 systolic and not more than it by refraining from rapid infusion of fluids until there is control of bleeding. There is a large and growing body of literature that supports the concept that keeping the patient hypotensive slows the bleeding, prevents hemodilution, and, strangely enough, does not increase the incidence of acute tubular necrosis in the kidneys.

            Here at Ospital ng Maynila we still believe in the rapid infusion of fluids before and after the prompt identification and control of bleeders for the resuscitation of hypovolemic shocks secondary to hemorrhage. How many times have we gained success or continued to fail? Are we putting our selves in jeopardy in the future for continuing to do so, as hard habits die hard?

As stated by Dr. Ken Mattox and I quote:

            “Please mark my word. Within no less than 10 years, probably even less than 5 years, any [one] that raises the blood pressure to higher than 3/4 the pre injury level, especially if using crystalloid solutions will be severely criticized as violating one of the indicators, whether the injury be penetrating, blunt, elderly, child, or one's own self or family.

Also mark this down on this date. The final target for a prehospital or EC measured BP will be that greater than 80 SYSTOLIC will be the level that the QA moral police will cite that those of you who believe in two large bore IVs, Rapid infusors, interosseous and sternal infursors, the 3 to 1 rule, and cyclic hyper resuscitation as causing unnecessary complications, deaths, and costs.”

            We could either follow or not depending on what side are we; afterall this concept is still under debate.  In medicine there are no absolutes. Just remember to include God  as your guidance always and not to play God by yourself.