Indexing Title: DCHUA’s Medical Anecdotal Report [05-1]

 MAR Title: Heart of the Matter

 Date of Medical Observation: January 24, 2005

 Narration:

             Long past the time for elective operations did our group venture with the last case for the day, a seemingly endless amalgam of cancer and reconstructive surgery.  As we placed the final stitches, looking towards another duty night, in came a forty-three year-old patient with a stab wound to the middle of the chest.  His vital signs were failing and we prepped the patient for an operation even as he his airway was being secured by the anesthesiologist.  I dispensed with my waterproofing gear to my dismay.

             There was no time to get an x-ray of the chest to confirm the absence of bleeding around the lungs.  The assailant seemed to have been well versed with the position of the victim’s heart, even though the classical triad of pericardial tamponade was not evident.  The abdomen of the patient seemed also tense, his consciousness having much earlier wavered beyond the point for communication or cooperation.  We sliced into the left chest of the patient, the wound being just to the left of his midline.  The fountain of blood was yet to be accessed thru opening the tense sac around his failing heart.  Would his blood pressure recover as we freed the trapped pump, or would it drop further as we opened the dam?

             All the theoretical surgical pitfalls coalesced around my feet, hitting the internal mammary artery, seeing the arrhythmia while handling the heart, trying to suture a moving target, seeing the difference of two ways of applying a horizontal mattress suture, and seeing the coronary arteries glaring at me, just asking for an massive heart attack with a mere millimeter of suture misplacement.

             Notwithstanding the two liter blood loss, the patient did not improve after repairing the rent in his right ventricle.  The surgical team split in two to address the probable intra-abdominal hemorrhage, while the other confirmed the diaphragmatic injury and sought to repair this breach of the boundary between the chest and the abdomen.  The remaining two liters of the patient’s blood was found in the abdomen, where the knife had sliced clean thru the liver.  Horizontal mattress (reverse kind compared to previous) sutures applied seemed to cut thru the liver substance.  After repeated attempts, with the patient having but water (non-clotting) coursing thru his veins, gauze packing was placed around the oozing liver, the abdomen closed temporarily, and the patient brought to the recovery room where he expired after another two hours.  Cherry colored fluid continued to come out of the drainage tubes placed into his chest.  Only one tenth of the blood lost was replaced with transfusion.  Was there any other possible outcome?