Surgeons can do amazing things. They can remove an appendix that is about to burst, bypass blocked arteries in the heart, or even carefully excise a tumor from the brain. But surgeons never work alone. They always depend on the human body’s intrinsic abilities, the ability to clot blood, the ability to combat bacteria, and the ability to heal.
A surgeon knows that if he removes a gangrenous appendix the patient will get better, but it isn’t the removal that makes him better. The surgeon assumes that the stitches will stop the bleeding at the site where the appendix was removed, the immune system will clear away the residual infection, and the skin and deeper tissues will heal themselves together again.
I always assumed that, too, until I met the man who wouldn’t stop bleeding.
Met is probably the wrong word, since my first encounter with him occurred while he was under general anesthesia on the operating table. It was early in my internship year and I was called to the operating room to provide assistance during a disaster of major proportions. A young man undergoing a surgical repair of a damaged artery would not stop bleeding. I was called merely to hold the retractors that kept the surgical wound open so that the surgeons could see the area in question. Another intern had been holding them for many hours and I was sent to relieve him.
The surgery, which had been scheduled to last 2-3 hours, had been going on for more than 12 hours with no end in sight. On the wall of the operating room hung the empty plastic bags that had contained the 40 units of blood that had been given to the patient thus far. As I stepped to the table, having gowned and gloved, I could see that the wound was filling with blood as fast as the surgeons could suction it away. One of the surgeons noticed my presence and explained what was going on.
The young man, in his late twenties, had been diagnosed an aneurysm of the main artery feeding one of his legs. An aneurysm is a weakening and ballooning out of a blood vessel wall that will ultimately rupture (and kill the patient) unless surgically repaired. It usually occurs in people over age 60, generally smokers. While the surgeon who had planned the operation had recognized that an aneurysm in a young person is quite unusual, he hadn’t fully considered why this unusual event had occurred. Unfortunately, he quickly found out when he attempted to repair the artery.
The artery in question, indeed all the patient’s arteries, were unusually weak. We later learned that the patient suffered from a rare genetic disease that made his artery walls abnormally thin and weak. At the time, all we could see was that the artery would not hold stitches.
The aneurysm had been excised during the first hour of the surgery. In the subsequent 11 hours, the surgeon, ultimately aided by two colleagues, struggled to close the residual hole in the artery. Yet every time they successfully stitched it closed, one or more of the sutures tore through and a torrent of blood poured from the artery. The situation was truly desperate, and desperate situations call for desperate measures.
It was impossible to close the blood vessel perfectly, as would have been required in any other patient. The decision was made to close the artery as completely as possible and to control the residual bleeding with pressure. Just like you or I might stop the bleeding from a cut by applying pressure, we would try to do the same, except that the pressure would need to be applied inside the body, not outside.
The wound was packed with as much sponge and gauze material as could fit inside, and the incision was left often. The patient was transferred to the intensive care unit with the recognition that either the bleeding would gradually stop or the patient would die. The patient left the operating room 16 hours after he had entered it and the vigil began.
Amazingly, and against all odds, the bleeding slowed and eventually stopped. Although the artery itself was defective, the patient retained the ability to clot blood, and the combination of blood clot and pressure ended the bleeding. No one dared to risk further bleeding by removing the packing, so it was decided that the wound would be left often to heal itself from the bottom up.
And that is precisely what happened. Within several days, the artery healed itself, and we began gently changing the packing each day. It took 3 months for the wound to heal completely, with progress measure by the gradually decreasing amount of gauze sponges that could be fit inside the wound. Initially I would arrive at his bedside each day with a seemingly inexhaustible supply of gauze to replace the old packing. After 3 months, I needed to bring only a large surgical bandage to cover the wound.
Ultimately the patient walked out of the hospital alive, a tribute to the body’s ability to withstand tremendous trauma and to heal itself, even under less than ideal conditions. Unfortunately, the story does not have a happy ending. There was no way to treat underlying genetic defect in his arteries and several years later another aneurysm developed in a different artery. This time the surgeons could not get the bleeding under control no matter what they tried, and the young man eventually bled to death.
