Wait, watch, act

It’s Friday just before 6pm in Paoua. The day started with rain but the sky cleared well before noon. As Paoua is only five degrees north of the equator, the noon day sun is directly overhead as we near the solstice.

It’s Friday just before 6pm in Paoua. The day started with rain but the sky cleared well before noon. As Paoua is only five degrees north of the equator, the noon day sun is directly overhead as we near the solstice. It’s a bit of a treat for me as I normally live 15 degrees north of the Tropic of Cancer where we never see the sun directly overhead though I might not find it such a treat if I was working outside though in the heat.

A few posts back I mentioned a trauma patient who had his spleen removed in the OR. For the non-medical reader, trauma is often divided into two categories, “blunt” (car accidents, falls, beatings, etc) and “penetrating” (gunshots, stab wounds, etc). In the US, the spleen is said to be the most commonly injured abdominal organ after blunt trauma.  Our patient in Paoua had sustained a “blunt” trauma and his spleen was bleeding. Other than that common point, there are few similarities between trauma care at home and here in rural CAR.

In the US and other “developed” countries, trauma care focuses on a government-funded system of first responders that expeditiously get injured people to a trauma center where they can be diagnosed and treated for life-threatening injuries within the first hour or two after injury. This is the so called “golden hour” where expert intervention can save lives after potentially lethal injuries. In Paoua, there is no government-funded system for water and electricity let alone a trauma system. After a traumatic injury, people may arrive hours or even days after their injury. If someone here receives a life threatening injury that might be routinely saved during the “golden hour” elsewhere, they will likely die before reaching the hospital.

Our patient from the other day first presented to an outside clinic, where there is no surgeon, when he still felt too weak to stand several days after being beaten with fists and sticks. He was admitted to the clinic with a swollen, distended abdomen and increasing pain, given intravenous fluids, evaluated with an X-ray and a blood count, suggesting blood loss, followed by a phone call to our project chief and a discussion with me about transfer. At home this patient would have had a CT scan to identify whether he had an injury to the spleen and/or liver, plus checked for signs of other injuries that would suggest he needed surgery. With a stable liver or spleen injury, he would be placed at bed rest to minimize the chance of recurrent bleeding. Here in the Central African Republic the choice was to risk leaving him at a facility that had no capability for an operation or transfer him to Paoua by LandRover with the risk of making any potential bleeding worse, as the trip is slightly less jarring than playing a game of rugby. We told them to send him over as soon as they could. Due to a combination of vehicle availability, road conditions and security issues, it was a full 24 hours before he arrived in Paoua, now almost six days from his initial injury.

When I saw him for the first time in the hospital, my initial impression was that he looked ill but not overly sick. His temperature, pulse rate and blood pressure, the so-called vital signs were all normal, a good sign. Someone at the clinic had placed a nasogastric tube into his stomach, a standard treatment to relieve abdominal pressure, before his transfer. There was only a small amount of green material that had been in his stomach, another good sign though he was still abnormally distended. When I listened to his swollen belly with my stethoscope, there was little if any sound of intestinal movement. He was tender everywhere I touched him, more so in the upper part of the abdomen.

Considering the possibility of intestinal leakage from the stomach, small intestine or colon, I examined him for signs of peritonitis. There were none; he had no increased discomfort when I tapped on his belly or had him cough or when I shook the bed. And when I had him turn over onto his side so I could examine his back, he rolled over without any appreciable increase in his distress.

Next, I looked at his chart and saw that his blood count in Paoua was the same as it had been before transfer, low enough to suggest that he had bled as much as a third of his total blood volume into his abdomen. But between the normal vital signs and the absence of a further decrease in the blood count it was unlikely he was having any more significant bleeding. Given his history and exam, my best guess was that either his liver and/or spleen had been injured during the beating and bled a liter or two, then stopped. I was concerned about the risk of the bleeding starting up again plus the possibility that a second injury to either the pancreas or intestine was causing his ongoing distress. But I was satisfied that there was no clear need to rush him to the OR for either peritonitis or rapid, ongoing bleeding when the doctor who had seen him just before me, a local national doctor charged with seeing all new admissions to the hospital, came over and asked when we were headed to the OR. It turned out he had taken the initiative to “tap” the man’s belly with a needle and syringe (a bold though possibly dangerous and injudicious move) and not unexpectedly found bloody fluid. I tried to suppress a grimace and explained that it was likely old blood from the original injury and we would hold off going to the OR until we had signs of ongoing bleeding or evidence for some other bowel injury or infection. I could tell from the look on his face that he understood the reason for my grimace, that his “tap” had not given us much useful information but had the possibility of having either introduced infection or even caused an injury to the bowel. I told him not to worry about it, ending with a smile and adding the ubiquitous “Ca marche” (translated roughly as that works for me).

We watched our patient for the next five days, each day checking his vital signs, how he felt, his abdominal examination and his blood count. We saw him on morning rounds and I checked on him every day before leaving the hospital and anytime we were back after hours for an emergency caesarian section. Some days he felt better and his belly was less distended, some days he was a little worse, but each day his vital signs and blood count were stable so I was still hopeful he would simply recover on his own without surgery. But on the morning of the sixth day, he had a fever to 102 F (38.9 C), felt worse and was extremely tender and tense over his left side in the area where you find the spleen. His blood count was still stable but that didn’t preclude new bleeding; the blood count can be the last thing to drop when bleeding first begins. Concerned that he was either bleeding again, had an infection in an old blood clot or possibly was showing signs of a late developing intestinal leak or pancreatic injury, I decided that we should operate that morning.

In the operating room, I made an incision down the middle of his abdomen going through all the layers except the last one, a thin, semi-transparent layer called the peritoneum.  Through his peritoneum we could see distended intestine floating in a midnight blue sea of old blood. I opened the peritoneum, placed a large retractor to hold the abdominal cavity open so we could see, then scooped out handfuls of clot and old blood followed by rapid placement of large white towels, so-called “lap sponges” in the abdomen. A quick inspection of the liver and pelvis confirmed that all the bleeding had come/was coming from the area of the spleen. The spleen and its surroundings were enlarged though it was impossible to say how much of it was spleen and how much was clot.

The next step was to bring the spleen forward and to the center of the abdomen as quickly as possible, up from its usual hiding place tucked up to the left and back under the ribcage. This was made more difficult than usual because the injury had been present for over a week and the healing process had already begun, with fibrous adhesions obscuring the normal space between the spleen and the ribs. But after a little grunting and groaning and muttering, I had the spleen forward in plain view. Now was the time for slower, thoughtful movements for clamping the arteries and veins. You have to be careful here or the tip of the pancreas can get caught up in the clamps. I clamped the main artery and vein for the spleen and then put clamps on the 'short gastrics', a few pair of smaller blood vessels going from the stomach to the spleen. Then snip, snip and the spleen was out. We tied the clamped arteries and veins, placing double ties on the larger vessels and now took a moment to inspect the spleen.

His spleen looked as if a fire cracker had gone off in the center. There were several fracture lines going through it and a mix of old clot and fresh bleeding mixed together, but no sign of infection. The pieced together spleen seemed a bit abnormally large to me, maybe two to three times normal size, but without a pathologist to examine it, I might just be buying into the surgical urban legend that speculates there is a higher risk of injury to the enlarged spleen, including in areas where malaria is endemic.

From here on the operation was routine; check for bleeding where the spleen used to be, examine the rest of the organs carefully to be sure there are no other injuries, check for bleeding again, place a drain (just in case there was an injury to the tip of the pancreas), make sure that all the “lap sponges” are removed from the patient, check for bleeding again and sew things up. The whole process took about 90 minutes.

I said earlier that there were few similarities between trauma care in the US and here, but there are a few. You can watch most stable patients but when things go south you need to take action quickly. The operations and their pitfalls are more or less the same, even if the spleens are a little larger and the patients a little thinner. And then there is the phenomenon of “some dude”.

When I first met our patient, someone asked who had beaten him and why. He said he didn’t know the people who beat him. I was later told that it happened during a family disagreement. A few blogs back I wrote about another young man who had been stabbed in the chest just inches from his heart and major blood vessels but somehow escaped serious injury. That patient also claimed not to know his attacker’s identity or motives. It brings to mind my time spent on our trauma service during residency when more often than not the answer to the question of  “Who did this to you?” came back “…Wow, man, I’ve got no idea….it was just some dude..”. It seems to me that “some dude” is a cross-cultural, international player in the trauma game.

To finish up, our patient is doing well three days after his operation. He was sick for a good week before his operation so I won’t be surprised if it takes him at least another week to recover. Without his spleen, he is more susceptible to certain infections so before he leaves the hospital he will get vaccinations against certain types of bacteria. He will be given instructions to get the vaccinations repeated every ten years and seek medical care for antibiotics whenever he gets symptoms of a cold or fever. But whether in the US or the CAR, patients don’t always follow their instructions to the letter. All we can do is hope that he hears our advice and takes it to heart.