I Don’t Need No Sternal Saw – Miracle #1

Do You Believe in Miracles?  I Do After Seeing One

Or

“I don’t need one of those sternal saws!”

Do you believe in miracles?

It is often difficult to really believe miracles actually happen, that is, until you see one, or even more surprising, when you find yourself right in the middle of one.  Twice during my career I have been in the middle of something that ended surprisingly well and there was no other way to explain what had happened other than to attribute the outcome to a miracle happening right in front of my eyes.

As one became more senior in the Anesthesia Department where I worked for nearly 40 years, one was often drafted to do what can only be described as ‘heroic’ cases, cases that are not necessarily expected to end well but are often the patient’s only recourse.  It seemed that as my tenure grew within the department I was asked to do more and more of these cases.  Not sure why.  Was it because I had a life-time of experience that I could call upon as the case and the patients condition began not following the usual expected course.  I would often say  I would need to do some ‘McGyver’ anesthesia.  Or might it be because it was not fair to the younger more inexperienced folks to have to manage cases, which if they did not end well, would permanently alter their feelings of confidence in their skills and training.  Regardless, all too often, I would find myself at the head of an operating room bed trying to reassure such a patient, just prior to anesthetizing them, that I was sure things would go fine and that I would take very  good care of them.

I was a pretty good anesthesiologist, anal about how I organized my room before a case, thorough about reviewing the case and the most recent literature the night before, knowing all the possible drugs I may need to give (that may count into the 30’s or 40’s), any special procedures I might have to do during the case … and most importantly making arrangements with one of my colleagues that I knew I could call if things really turned bad.  There were three or four of us that became very close and I knew any one of them could be part of my ‘extended team’.  I knew that if I were to broadcast out  a request for  help they would come running, no questions asked, no recriminations about needing help, just, a ‘let’s get it done attitude’.  But even with all the preparation, even with all the back-up I had in place – if a miracle were needed and if a miracle were to happen, I would take it for what it was – ‘A Miracle’.

One such case happened about 20 years ago.  It was a sunny afternoon and I made my way down to the operating room to find the cases posted for me to manage the following day.  The first tinge of concern came as I saw the surgeon scheduled for my room.  He was an excellent Orthopedic surgeon, an identical twin just as I am, so we had had many interesting conversations about our twin brothers and the challenges and joys of being twins.  Many of my colleagues from England would say he was a fine ‘chap’, so we gave him the nickname, ‘Dr. C,  Unfortunately, he was also notorious for doing many of these ‘heroic cases’, cases that would bring the feeling of dread to most of the anesthesiologists assigned his room.

Sure enough, there it was, first case of the day.  A 55 year old man, scheduled for a ‘hemi-pelvectomy.  He was from a neighboring state.  He had been previously healthy, had taken care of himself so was in very good shape, and that evening when I went to see him.  He was in his room with a lovely wife and two grown sons.

Yes, the procedure he was to undergo is just as bad as it sounds when I describe it to you.  He was an unfortunate patient who had a particularly aggressive cancer that was involving one half of his pelvis.  His only chance at a remission, or outside chance of cure, was to remove one half of his pelvis and the attendant leg – all of the left side of his hip, pelvis, thigh and lower leg – a surgery called ‘a hemi-pelvectomy’.  I had done many of these in the past and knew I would be having a sleepless night worrying if I had thought of everything I needed to have in place – “just in case”.

The day started like many of these same kind of cases had in the past.  I met the patient in the pre-op holding area with a nurse anesthetist who was assigned to do the case with me.  We discussed with him what we were going to do, confirmed some critical things about his health, allergies, medications and answered any questions he had.  I was stuck with how calm he was.  He really had few questions and then just said, “well let’s get started”.

We knew we were going to need to give him multiple units of blood, would need to monitor his blood pressure by directly measuring it in one of this main arteries, and we would need to watch how much fluid we needed to give which would require a central line – a very large multi-channeled IV in his neck that goes down into his heart (a central line).  Since healthy, we put all these lines in after we had put the him asleep.

The case began as they all did.  It took about 45 minutes to get him ready after he was asleep before we called for the surgeons.  Dr. C came in the room, and we were off.

As he made his incision, Dr. C told me he had invited one of the trauma surgeons from our regional trauma center to come over and help him with the case, particularly as he got to the large arteries and veins in his pelvis.  He also told us he was concerned about how the tumor had invaded the bones of his pelvis and that could lead to significant bleeding – bleed from bones is very difficult to control.  Both the arteries and  the veins of the pelvic bones are held open by the bones through which they pass so they are very difficult to clamp or control once bleeding starts.  In addition, because they don’t collapse when they are cut, they are at risk for allowing air to get in to the blood stream.

The case had been going about 3 hours.  The nurse anesthetist and I had been preparing the patient over that time for when things get ‘interesting’.  We had been carefully watching his lab values, making sure his electrolytes stayed within normal ranges,  slowly overfilling his circulatory system with fluid so that when he started losing a lot of blood, which he inevitably would, he would lose fewer blood cells, just more fluid, and then we could get rid of the fluid by giving diuretics at the end of the case if needed.  We really wanted to be ahead of things because we knew what was coming.

I had just re-entered the room to check on things.  The nurse anesthetist and I were talking at the head of the bed, reviewing the anesthetic record, re-assuring ourselves that things were in order as we were nearing the critical parts of the surgery – when all of a sudden.

We heard our monitor alarm and we both looked up at it and saw that in one instant the patients blood pressure had dropped from normal to zero, not just fallen a bit, but had gone to ZERO!  What may sound weird, however, was that he still had a heart rhythm but absolutely no blood pressure.  We looked at the ventilator monitor and saw no carbon dioxide coming out of his lungs as well as the presence of nitrogen, meaning regular room air was coming into his lungs from his blood.  Both of these could mean only one thing.  The patient had just had a massive air embolus – that is such a huge amount of air had tracked back in through the veins of his pelvis – that it had gone to his heart and was causing an ‘air-lock’ in his right ventricle.  The ventricle was full of air, and not full of blood, so the heart was unable to pump blood out to his lungs and body.  Such a massive air embolus is usually uniformly  fatal.  We had hoped that by giving all that extra fluid we would have been able to keep his the vessel pressure in his veins high enough that that would not happen.

Immediately we had to do whatever we could to get the air out of his heart and do it quickly.  We had placed a very large fluid administration tube into his neck and down into his heart to both be able to give fluids and blood quickly, but also for an event just as this.

Dr. C noticed something was wrong and asked, “What’s going on Brian?”  I said, Dr. C. I think you patient just had a massive pulmonary air embolus, flood the surgical field with fluid, now! And Lots of it!!

He started pouring liters of fluid in to the man’s pelvis and looked me right in the eyes and said, “Ross, you better do some of the magical Anesthesia shit or we are going to be in big trouble!!”

We immediately put the patient head down, tipped the table so his left side was down a bit, all standard reactions to air embolus.  But I knew we had to get that air out of his heart!

We hooked a very large syringe (60 ml) onto the large IV tube in his heart and tried pulling air out of his heart, but with little success.

At just that moment Dr. P. the trauma surgeon walked in to the room.  He had a mask on but was still in his short sleeve scrub shirt and blue scrub pants but had not put on his surgical gown and gloves yet, as he was just coming in to see how things were going.  He looked at me and knew we were ‘waist high in it’ and asked what was going on.  I told him the patient just had a massive air embolus and we needed to get the air out of his heart, NOW!, and we weren’t having any luck with the central line.

He said, “well, then, let’s get his chest opened up”.  I knew that was his only hope.  The scrub nurse heard that and started yelling as the circulating nurse, “get the me sternal saw, get me the sternal saw”.  The sternal saw is a power driven saw that looks a bit like a sabre saw that is used to cut the breast bone down the middle to open the chest, mostly used for heart surgeries.

Dr. P looked right at the srub nurse and said, “I don’t need no damn sternal saw”.  He reached out with his bare hands and grabbed a scapel off the sterile instrument table, and in one swoop incised the patient’s chest from his breast bone to nearly his backbone.  He dropped the scapel on the floor and shoved his ungloved hand into the guys chest and started open chest massage on the heart.  He looked at me and said, “yep his heart has air in it, it’s full of it”.   “We need to get it out, give me that big syringe you are using and a very large needle.”  By that time the syringe was certainly no longer sterile, but as this was the patients only chance, and I had a bucket of antibiotics I could call upon, I put a very large needle on the syringe and Dr. P pushed the needle into his heart and filled up the syringe with air from his heart.  He did that about 5 or 6 more times, and then when he was sure he had most of the air out started open chest heart massage again.

“Now we are making some progress”, Dr. P said.  I looked up at the monitor and just started seeing the meagerest of blood pressure but a measurable blood pressure none the less.  His blood pressure was very low,  but at least it was present on the screen.  I had always believed a very low blood pressure was better than no blood pressure at all.

It had seemed that through all of this, time had stood still, but in fact it had been no more than minute  from start to finish.  We all started to breathe again, and together looked around the room in total disbelief at what had just happened.

There was a lot of work ahead but at least the patient was still alive.

Dr. P. went out of the room to wash his hands and arms and put on a surgical gown and sterile gloves.  As he came back in to the room a few minutes later, Dr. C. asked me, “Ross, what do you think?  How is he doing?”  I told him we were supporting his blood pressure with drugs, his oxygen need was very high and his lungs were requiring pretty high pressures to ventilate.   I told him that he had experienced a very severe lung and heart injury and I thought that it was still very likely the patient was not going to make it.

As Dr. P. began the process of closing the large wound in his chest I noticed Dr. C. had left the room.  I said to Dr. P., where the hell did Dr. C. go?  He said that Dr. C. had all the bleeding controlled in his pelvis and he felt he should go out and talk to the family in person – a very reasonable idea actually.

A few minutes later Dr. C. returned to the room and with him was a guy in a green ‘jump-suit’, an outer cover that people who need to come in to the operating room can wear in leu of putting on surgical scrubs.  I was wondering what Dr. C. had in mind, but I was busy getting blood tubes ready to send off for yet another set of blood studies.  The man took a position at the head of the patient – he looked about as green as his jump suit – not surprising from the scene he had just taken in.  I noticed he got out a rosary and some oil to anoint the patient and it struck me Dr. C. had gone out and retrieved the family priest who had accompanied the family over from their home state.  It struck me that he may be giving the man his last rites.  As he was finishing up I reached past him and drew a lengthy set of blood specimens.  At that moment I elected to believe that Dr. C  was not making a statement about his confidence in my ability to turn things around but more of facing the reality of the situation.

The priest left the room and the nurse anesthetist and I began the hard work of trying to turn this case around.

About 10 minutes later the results of the labs we drew were brought in to the room.  During this type of emergency the lab sends a portable satellite lab cart and positions it just outside the room so we have nearly immediate turn around of results.

The nurse anesthetists and I looked at the monitor and were surprised that the patient was starting to miraculously improve.  I took the lab slip from the lab technician and shared it with the nurse anesthetist.  We were both stunned.  Every single lab test, every one we had sent returned absolutely normal – what we call in the business, ‘u-boxic’, all of the numbers perfectly in their normal values or their normal box.  I was stunned.

I turned to Dr. C and said, “I can’t believe it Dr. C. all of his labs are perfect, perfect!”  The patient was also very quickly requiring less and less medication to support his circulatory system, and he lungs were acting like nothing at all had happened.  The nurse and I looked at each other and simultaneously said, “this is a miracle”.  We both wished we could take credit for what we were observing but knew otherwise.

After composing myself a bit I asked Dr. C, “Hey, was that this guy’s priest you just brought in here.”  He said, “yes it was, I told the family what had happened and that we were not sure he was going to make it.  They asked me if it would be alright if the priest came in to administer the last rites.”    I then told Dr. C. that that priest must have very good connections as I thought the guy was going to actually make it.  Then in passing I asked Dr. C, “can you ask that priest to come back in here and pray up a nice new black Mercedes sports car for me.  He seems to be able to make miracles happen”.

Five hours later we were taking the guy up to the intensive care unit where I visited him regularly for the next 5 days.

The end of this story for me occurred about 3 weeks later, on the day this man left the hospital and returned back to the state from where he was referred.