Monday, July 09, 2012

Weekend masked avenger..

 This will be my first entry which is directly related to my work here.I thought the days of terror and excitement is a long gone memory; having many of those in my journey towards qualifying for my specialty. Last weekend was definitely one of the highlights of my career! A definite tale to my students later on in my life :)
  Reza mentioned to me on Friday evening, that blood bank is having problems issuing blood due to their computer system malfunction.Jokingly i told him, its a sign for a torrid weekend as both of us will be on duty. Masin tak masin mulut.. hahaha
Saturday was a busy day as we had a cadaveric donor; thus the theatres were activated for cardiac and lung transplant; followed by renal transplant. Somehow, blood was not an issue on that day as they managed to make it work again.We had a sick laparotomy.. and boy, was she sick. She was compensating well as per induction when our first ABG later showed how severely acidotic she was! She was managed well resuscitated and of course destination ICU. She needed quite a high dose of Noradrenaline.. as she was severely septic.. however it was never as bad as the laparotomies back home!
Sunday was the ultimate killer.. upon my arrival I was summoned ; a heavy duty case of a person who arrested in theatre the week before.A young Liver cirrhosis suferer with all the typical features.We had everything ready;Andreas was the Consultant and Stefan was there as well. the Level 1 infusion pump.He he came to OT with Hb of 5.He bled in the ward and was resuscitated but needed an urgent scope which we decide to do it in OT.
The scope looked not too bad, except there was a big clot just sitting in the oesophagus. No active bleeding was seen and i thought, ok not as bad as i thought. However, as soon as the clot was sucked out.. there was a sudden gush of blood.. RED HOT FRESH BLOOD.. flowing like a broken pipe from the mouth.
As soon as i saw that i shouted to Stefan.. RED BUTTON NOW!! He is not going to do well!!
Blood poured out like hell and the BP which was 90-100 earlier, was coming down rapidly... 70..60..50.. and we pushed in fluids as fast as we can to maintain the volume. Noradrenaline was pushed up sky high..
The Gastro fellas tried to inflate the Sengstaken-Blackmore tube.. but the hole must have been damn big to be sealed by it.He had to be maintained in the almost prone scope position in order to somehow halt the bleeding.We needed a central access and Andreas initially scanned his neck to see the possible vessel. He asked.. you want to have a go? Haha I've never ever done one in this position.. totally unconventional but we needed that access.
I must say this is why ultrasound is so useful as you can visualise it and have a go! Haha.. Alhamdulillah, despite the technical difficulty in the positioning, i managed to insert the swans and yes.. the Level 1 infuser was redirected.
At this point there was nothing that the gastro can do, intervention radiologist was called in to offer their expertise. This was then our next challenge.. His BP was 40-50 systolic and still losing massive blood.. we had to continue this all the way down to the Intervention suite. Haha with my special Adrenaline boluses.. we managed to transport the patient down, along with the Level 1 infusor.. on going as we move!
Thank god for Prothrombinex as well, we managed to somehow maintain his coagulation though at this point, it was definitely not his anymore as he was transfused like mad! We had more than 30 units of packed cells given to him and most of it came out anyway! The Senior Radiologist managed to embolize the vessels feeding it out and he slowly had less blood coming out from his mouth.. His inotropic requirement which was over the roof ( imagine.. 80ml/h of Quad strength??) came down dramatically and.. after struglling for 5 hours.. he was ready to be transported to ICU! haha Even the ICU COnsultant was impressed how we managed to maintain him with all that had happened!
It was good team work and I certainly will cherish this unique experience. I guess, the first that did survive the acute ordeal.. back home, Usually we are not able to maintain the circulation that fast for that long because of our resources. Patient would go really anaemic and thus the heart compromised. We somehow managed to transport minimal oxygen required while maintaining the circulating volume.
Peerrghh.. and I was tired.. so tired that today, it was not until noon that i decide to get out of bed :)

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