INTO THE VALLEY OF DEATH

Seeing a person bleed is a tough thing for most people. I know girls who faint at the site of a needle entering a vein. Now imagine making a large cut on the skin, then going deeper and deeper to the deepest reaches of the human body. Controlling blood loss is one of the pillars of modern surgery.  And after a while, it seemed easy enough to me as well. Until one night,when we got a call from our colleagues in Nephrology.

The department of Nephrology (Kidney doctors), helps a lot of people with end stage kidney disease. These are people whose kidneys are so badly damaged that they can’t continue living without dialysis. This doesn’t have much to do with general surgery though, so getting a call from them at our emergency at 11 pm was a bit odd for us. My senior resident attended the call and 15 minutes later, he called me in the emergency room to tell me that I had to get the Emergency Operation Theatre informed and prepped for a case of trauma to the abdomen.

The patient that rolled in on a trolley was a young boy, who must’ve been 17 years old. He seemed to be in shock, and when I saw his Hemoglobin (the red pigment in the blood that carries oxygen), I flipped. It was 2.7. The normal should’ve been over 10. As soon as they laid him on the table and exposed his abdomen (called the stomach in lay terms), I saw a strong reddish –purple discoloration of the right side and the back. The senior resident quickly filled me in while we waited a few minutes for the Consultant to arrive.

This boy was a patient of End Stage Renal Disease. His body had turned on his own kidneys and damaged them to the point of no repair. He used to come to our hospital for dialysis twice in a week. And that night he had an accident. While walking home, he had been hit by a car. The driver, who was drunk, had swiveled on a curb. The car had skidded and the boy had been hit hard on the right side of his abdomen from the back. Instead of coming straight to the emergency, the father took him straight to the Nephrology Department, the only doctors he was most familiar with.

The Consultant arrived and we opened him.  As soon as we opened into the abdominal cavity, we were greeted by a large blood clot. We got it out of the way, fast. On further exploration, we couldn’t find a single large blood vessel that had been injured. The blood was coming from a large laceration of his right kidney. We had to take it out. There was no way of fixing it. Whatever minimal function it was providing would go. But the patient was on lifelong dialysis anyway. So we took it out. We controlled the blood loss. We closed him. We transfused him with lots of blood and platelets. We saved his life. Almost.

The next morning he seemed better. We had placed a drain in the place where the kidney was and there was no blood coming from it. That was good news. His Hemoglobin though, had only risen to 4.8. Given that we had transfused him adequately, it seemed too low. Still, we were hopeful. We had an Ultrasound scan of the abdomen done just to check anyway. This time, I called the senior resident, and we went back to the Emergency Operation Theatre. On the Ultrasound scan, we found a large clot in the same area where his kidney used to be. Although, we had placed the drain, a large blood clot had occluded it. He had to be operated again.

This time, we took out the blood clot again. It was significant. Almost 130 cc. we tried to search for the bleeding. But we couldn’t find the source. There was no bleeding vessel or organ. It seemed to be emerging from the walls. Just diffusely pouring down in little drops everywhere to form a puddle in the area where his kidney used to be. We cauterized the bleeding points (made small burns that coagulate and block the points of bleeding). Most of the bleeders stopped. Except from this little crevice at the upper part of the cavity we had opened. The bleeders here were so tiny, that the blood just seemed to emerge out of nowhere. No problem. We tried to cauterize it. But it didn’t work.  The bleeding re-emerged. We took an Artery forceps and tried to tightly clamp a good part of the underlying tissue. Five minutes later, when we removed it, the blood emerged with the forceps. We took a good bite of the tissue in a hemostatic suture. We tied it, and tied it, and it failed. In fact, the act of putting the needle through the tissue just made it worse. We extended the skin incision so we could see the area better. Maybe there was some large blood vessel we had missed. But there wasn’t. The blood just refused to stop coming. The puddle would just emerge out of nowhere in that deep tiny, crevice. We were scared that if we explored further, we’d just make things worse.

We had used all our tricks in our bag. There was only one thing left to do. We packed that crevice nice and tight, with Surgicel, an absorbable sponge that would pressurize it temporarily and over that with snugly fit towel mops. Eight of them to fill the entire opening. Then we tied the area with bandage. And we waited. We waited for 48 hours.

Meanwhile, we investigated the patient for the cause of such inconspicuous, unstoppable bleeding. His coagulation profile seemed deranged. But not by too much. And then, our nephrologist friends pitched in with a D-Dimer report that showed more than moderate elevation. This meant that this boy had Disseminated Intra vascular Coagulation. His weakened state due to his pre-existing kidney condition, and his blood loss had made his blood clotting system go haywire. His body had probably consumed all his clotting factors in making the large clot that he came with. If he just had a bleeding vessel, the clot would have stopped it. But his kidney had been lacerated due to the accident in such a way that it bled slowly and continuously from multiple small parenchymal arteries in the kidney. The irony was that this had kept him alive till he got to the hospital. The blood hadn’t emptied form him fast enough to kill him quick. But this had also led to his present dangerous condition.

We tried correcting whatever abnormalities we could. But by evening, even through the eight towel mops we had placed in him, we could see blood soakage from the corner of his wound.  Thankfully, his Hemoglobin wasn’t dropping. So we decided to keep waiting for the standard 48 hours to get over. It was a tough 48 hours. The pressurizing mops had irritated and obstructed his gut. It wouldn’t move and so he kept vomiting every hour. The pain was very bad. He was drowsy from lack of sleep, because the pain and the fullness and the nausea kept him awake inspite of medication. 48 hours, I said to myself. Just hold on. I was scared that in his drowsiness, he would aspirate his vomitus. That would be fatal. We tried placing a stomach tube to prevent that situation, but he wouldn’t tolerate it.

Somehow, the 48 hours went by and we took him back to the OT. We started removing the mops, slowly, very slowly, one at a time. It reminded me strangely of a poem I had read in my early schooling- The charge of the Light Brigade. “Into the Valley of Death, rode the Light Brigade”, it said. Reaching that little crevice in the upper part of his wound, where walls of muscle created a valley where a little stream of blood would flow to become a pool and then a flood was one of the most tense moments I’ve seen in my six months of operative surgery. The deeper towels were soaked thickly with blood, but they were otherwise dry. That was a good sign. We took that last towel out so slowly, it seemed like an eternity. And there it was, the ‘Valley of Death’. Clean, dry, without blood. We went a step further and washed the whole wound. There was no blood. We placed a drain, and closed him.

After ten days under our care, the boy improved. Not only did he not have any more bleeding, his health got better with repeated dialysis. It was a miracle he survived. He comes for his dialysis regularly like he used to. Someday soon, we might re-enter that valley, on peaceful terms, and transplant a new kidney there.