Heart Beat:Heavy prolonged showers, propelled by a bitter north wind, have been marching down the coast all day and coating the hills with snow. From the comfort of the house it appears very beautiful.
The McGillicuddy Reeks, Seefin, just across the Caragh estuary, the mountains behind Glenbeigh and Drung Hill, off to my right, all appear ghostly white against a dark foreboding background as night falls. It is not an evening to be abroad.
During the previous week I had been in the company of a group of colleagues and one of them had reminded me of an episode from my surgical registrar days. It had happened over the St Patrick's holiday and I was on duty.
A patient had presented to the A&E unit, complaining of breathlessness and an X-ray had shown a large pneumothorax, ie a collection of air between the lung and the chest wall. It is usually caused by a little bubble on the surface of the lung rupturing and leaking air into this restricted space.
It is a fairly common condition and if the leak is small it may not require treatment. In this instance, there was a fairly large amount of air and it was beginning to compress the underlying lung.
My medical registrar counterpart, accordingly and correctly, asked the duty house officer to insert a chest tube to remove the leaked air and allow the lung to expand. All of this is routine and would not normally involve a surgeon.
The problem in this case arose when the doctor inserting the tube had the misfortune that the metal trocar or introducer for the tube glanced off an underlying rib, causing immediate and serious haemorrhage. This was not in the script but was a clear example of how even the most routine procedures can go horribly wrong. It was 2am and it had now become a surgical problem and an acute emergency at that.
Thus my phone rang and an agitated nurse requested my presence right away. The tone of the voice brooked no delay and the warm bed became a memory.
On arrival I found a patient in shock and a medical team with a major problem. In those far off days, the interns had the task of blood grouping and then cross-matching any blood required with the patient's own blood to eliminate the possibility of giving an incompatible transfusion with disastrous consequences. It was a highly responsible job that nobody liked.
The doctor was dispatched to acquire six units of blood initially and to ascertain if there was any type O negative blood in the laboratory, which could be given uncross-matched in dire emergency. My anaesthetic colleague arrived and set about providing vascular access (putting up drips in everyday parlance). This can be difficult in a shocked collapsed patient and so it proved.
It was absolutely vital to replace the blood volume that was being lost. We were dealing now in minutes. We had a seriously compromised patient, both in circulation and respiration from the original collapsed lung. The anaesthetist passed an endotracheal tube and we passed chest drains for air and blood into the left chest cavity.
A modicum of control was being established - we could replace volume being lost and we could control respiration. Appropriate blood was on its way, the operating room staff had been alerted and the relative consultants in surgery and anaesthetics had been summoned and told to go straight to the theatre.
We arrived there at a run through the darkened corridors of a sleeping hospital. In a short time the patient was on the operating table, stabilised as far as we were able. Blood had arrived and was being rapidly transfused and vital signs began to improve. This was, if we had time to reflect, very gratifying, but one major problem remained. What major blood vessel had been damaged and, accordingly, what surgical incision to employ?
It was venous rather than arterial bleeding and this gave us a little more time, but otherwise was of little comfort as major venous bleeding can be notoriously difficult to control.
In the event, the damage had occurred at the confluence of the main vein coming from the left arm and the major jugular vein on the left side of the neck. With all the swelling at the root on the neck and on the chest wall, it was extremely difficult to see the damaged area and more difficult still to control the bleeding and repair the vessels. More than once I felt that our patient was slipping away despite our best efforts.
Gradually, the bleeding lessened as the thin walled veins were repaired and finally at 9am we left theatre on a cold St Patrick's morning. The patient was transferred to the intensive care unit. He had had his entire blood volume replaced three times over, having received in excess of 20 units of blood. He made a full recovery.
Breakfast then and ward rounds to evaluate the overnight admissions and the inpatients. Then back to the residence to await what the day might bring. It later brought a lengthy discussion with the patient's family as to how it all had happened. That was not a problem, but those were different days and the compensation culture had not spread its tentacles into every aspect of Irish life. People accepted that "bad things happen" and not always can blame be apportioned.
Maurice Neligan is a cardiac surgeon.