The Gold Oak Ranch blog is a forum to discuss healthy lifestyles, good food, and the occasional good book, but I thought I’d take a detour today on the matter of health. As a practicing anesthesiologist, I see the value of good health every day I work. Healthier patients have better outcomes after surgery. Patients with good health tolerate anesthesia a whole lot easier.
But good health is not only the product of fortunate genetics and a prudent lifestyle. Good health is also good luck, and in the case of my patient a few weeks ago, bad luck struck in a flash of electricity, ruining the future of a 17-year old boy, and leaving myself and the health care team tasked with putting him back together again with the powerful feeling of the fragility of life and how lucky we are to escape disaster every day.
I’ll call him Justin, although that’s not his real name. I got a call about Justin the night before his operation, which means that the anesthesia scheduler was worried enough that he thought advanced notice was necessary. And it was. Justin had been in the hospital for more than two months when I met him. And like most of the critically ill, he had experienced at least one complication: infection. You can’t lie in a germ-filled hospital building for two months without catching something. And Justin had done just that, which necessitated the 9 hour operation we were about to undertake.
Before the accident, Justin had been like any other 17-year old boy. Not the best student, but certainly not the worst. He came from a good family who cared about him. What he did have was incredibly bad luck. He and his friends had built a bonfire, which had ignited a nearby tree. Your instincts might cry: forest fire! But it wasn’t that. The tree burned only enough to fall over, catching a nearby power line which sent a bolt of electricity through Justin.
Justin’s head was burned all the way through his skull to the tough covering of the brain called the dura. Later, during the operation, the pediatric neurosurgeon pointed out the scar on the dura where electricity entered Justin’s brain and spread though his body, exploding out one arm and through a foot. Terribly burned and unconscious, Justin spent his initial weeks in the County’s burn unit, where doctors and nurses struggled to save his life and prevent all the complications to which burn patients are so spectacularly vulnerable. Justin lived but he didn’t escape infection. The bone graft that the doctors had used to cover Justin’s brain became infected and now needed to come out.
One of the toughest aspects of providing anesthesia for burn victims is finding IV access. Burned skin is unsuitable for venipuncture, and the unburned portions of limbs have been poked for blood and IVs so many times that there isn’t a decent vein left. When Justin came to us, he only had a tiny IV normally used in toddlers. After struggling for fifteen minutes to put in a larger, more appropriate IV, I finally asked the surgeon to put in a central line, an enormous IV that travels beneath the collarbone through the big internal veins of the upper chest. Central lines have their own set of risks, but later, when things went to hell during the case, I thanked the Lord that I had insisted on it.
The surgeons had decided to put a muscle flap over the boy’s open head wound. They told me that to put in another bone graft would be to condemn the graft to infection. A muscle flap, because it has a better blood supply, would be more resistant to reinfection. The surgeons decided to use the latissimus dorsi muscle, the chest wall muscle most associated with the V-shape of a swimmer’s back. Flap surgery is long and delicate. Particular care must be taken to maintain the vascular supply to the flap and then to connect that vascular supply to the blood vessels serving the opertive site. Surgeons get particularly testy about patients’ blood pressure and medications that alter blood pressure, believing that some of those medications threaten the flap’s viability. And Justin, with his big hole in his head, really needed that muscle flap to work.
It was this concern for maximizing blood flow to Justin’s new flap that lead the surgeon to order dextran 40, a type of IV fluid that supposedly improves blood flow. The only problem is that dextran 40 has been associated with rare cases of anaphylaxis, and Justin, who had been unlucky enough to be electrocuted, was also unlucky enough to be one of those rare cases. In horror I watched as his blood pressure plummeted. Recognizing immediately that something dreadful was happening, I called for backup, knowing that anaphylaxis can kill a patient quickly. I was determined that Justin not die. He had been so unlucky, and now he was unlucky again!
My colleague walked through the door, took one look at Justin’s 37/12 blood pressure and cried, “This is for real!” Together we engaged in what we called ‘full chemical warfare’, pushing drug and after drug into Justin to bring back his blood pressure and stop the catastrophe that the dextran had triggered. The surgeons didn’t complain. They sewed furiously, trying to close the boy’s head wound, so that if we needed to put him on his back to start CPR, we could do so.
In the end, Justin stabilized. After nine hours of surgery, we brought him back to the pediatric ICU where his anxious family and friends waited. Exhausted, the surgeons and I returned to the OR to finish tying up loose ends.
I saw Justin the other day. He smiled at me and thanked me for giving him good anesthesia. I couldn’t help notice that, despite the fact that he had lost forty pounds, he was still a handsome boy. It also occurred to me that the muscle flap that we had so laboriously placed, which had been threatened by his anaphylaxis, was functioning well. The low blood pressure and the medications we gave to treat that low blood pressure hadn’t killed the flap.
Justin had been lucky at last.
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Wow Rachel, what an amazing story!!
my work is insignificant, WOW…can I still buy some oranges though
Well done!