Massive autotransfusion

I was working on the vascular anesthesia service on a recent Friday afternoon.  It was a fairly busy day and I was helping keep the ORs running smoothly by doing preop evaluations, lines, blocks, and assisting with inductions.  I was on my way to see a patient in the preop holding area when the preop nurse hurried past me.

"They're doing a pericardiocentesis in bed 11!" she informed me as she passed.

I went to bed 11 and took in the situation.  An attending cardiologist and a cardiology fellow were at the bedside dressed in sterile gowns and gloves.  The patient lay supine on the bed, a sterile blue drape over her chest.  A table next to the bed held a pericardiocentesis kit, opened and ready.

My first action upon arriving was to assess the patient.  She was awake, breathing oxygen via a non-rebreather facemask, and able to respond to questions.  She was tachycardic to the 120s; her heart monitor showed electrical alternans; and her blood pressure, measured by a femoral arterial line, showed marked pulsus paradoxus with MAPs in the range of 35-55.  In short, she had cardiac tamponade (a life-threatening condition) and looked pretty bad.

An ultrasound machine was at the patient's bedside and a technician was attempting without success to obtain a view of the heart and pericardium.  "Stop with the ultrasound, I'm going to have to do this blind," the cardiologist told the tech.

As I watched, the cardiologist introduced the pericardiocentesis needle substernally, aspirating via a 60 ml syringe as he advanced.  He directed the needle up and leftward, and his efforts were promptly rewarded with a gush of blood into the syringe as he entered the pericardium.  The cardiologist breathed a sigh of relief and continued drawing back on the syringe, filling it to capacity before laying it aside and reaching for another.

The patient responded quickly to the decompression of her pericardium.  Her blood pressure and tachycardia improved before our eyes and she stated that her dizziness had improved.  Color returned to her face and she breathed more easily.

After removing about 150 ml of blood from the patient's pericardial sac, the cardiologist used an over-wire technique to place a pigtail catheter.  He experienced some difficulty passing the catheter, however, and it was several minutes before the pigtail was in place.  During this time, the patient's hemodynamic status quickly deteriorated once again.  Finally, the cardiologist got the pigtail in place and began drawing blood from it.  Once again, the patient's status improved immediately after the blood compressing her heart was removed.

As the cardiologist drew syringe after syringe of the patient's blood, I became concerned about the sheer volume of blood being removed.  "I'm going to start giving this blood back to her," I told the cardiologist.

"Can you do that?" he asked.

"I don't see why not," I replied.

I grabbed the syringes full of blood (nearly 500 ml by this point, or about 10% of the blood volume of a grown person) and began pushing them back into the patient's bloodstream through her peripheral IV.  At the same time, the cardiologist hooked a 3-way stopcock to the pigtail so he could suck blood out with a syringe and then push it into a collection bag.  This new setup presented a problem for me since the collection bag was essentially a dead end -- it wasn't a bag that could be easily hooked to IV tubing, nor did it have a loop from which it could be hung.  And blood was still coming from the pigtail.

Fortunately, a solution soon presented itself.  When the cardiologist had struggled to place the pigtail catheter, he had damaged it and had ordered a new pericardiocentesis kit to be opened.  When the collection bag hooked to the pigtail catheter held about 500 ml of blood, I switched it with the bag from the second kit.  I spiked the first bag on regular IV tubing and quickly ascertained that the bag's port was slightly too large for the spike -- not large enough to leak, but large enough for the spike to slip out.

I joke with junior residents that most problems in anesthesia can be solved by a calm demeanor, tape, and the proper application of elbow grease.  This proved to be one of those times.  The preop nurse grabbed some 1" silk tape and we firmly anchored the IV tubing to the blood collection bag.  Then we used the tape to create a loop on the bag, hung it up, and started dripping the patient's blood back through her IV.

While we treated the patient, the cardiologist and I had been discussing what to do next.  He informed me that this woman had been undergoing coronary angiography and balloon angioplasty when the guidewire pierced her left anterior descending (LAD) coronary artery.  Per standard procedure, she had been placed on an anti-platelet medication prior to her procedure; unfortunately, that medication was now preventing her blood from clotting to repair the hole in her LAD.  The cardiologist wanted to go back to the cardiac catheterization suite to perform angiography, find the leak, and tamponade it with a balloon to seal the hole.

With this decision made, I went to my usual place at the head of the bed.  I told the patient what we planned, reassured her that we would take good care of her, and asked her to keep me informed if she started to feel lightheaded again.  And away we went.

By the time we arrived in the cath lab, the patient had begun feeling dizzy again.  I grabbed a pair of 60 ml syringes and began withdrawing blood from the pigtail catheter, again with immediate improvement of the patient's symptoms.  A nurse came over and together we formed an assembly line, I removing blood from the patient's pericardium and he giving it back through her IV.

Angiography was fruitless.  The cardiologist was unable to see extravasation of his dye and so was unable to find the arterial defect that needed correction.  As he examined the images, one of the hospital's cardiothoracic surgeons entered the cath lab.  He and the cardiologist conferred and concluded that the patient would require surgery to correct her LAD defect.  I called my attending and asked him to have someone prep the OR for us; he told me that someone was already setting it up.

And away we went again, this time to the OR.  I talked with the patient as we went, explaining to her what her anesthesia would entail.  She was understandably a bit shaken, and I reassured her once again that we would give her the best care possible.

We got her to the OR and onto the table.  The CT surgeon, justifiably concerned that her continuing hemorrhage and cardiac tamponade would make her crash after induction of general anesthesia, asked us to place her lines with her awake, then prep and drape, and induce only when he and his team were scrubbed and ready for incision.  My attending and I agreed and proceeded to get her lines set up.  Two nurses continued pulling blood from her pericardium and autotransfusing it back to her while we worked.  Since I'd started doing that, she'd had her entire blood volume removed through the pigtail catheter and given back through her IV.

The surgeon and his team scrubbed in once the patient was prepped and draped, and then they gave me the go-ahead to induce general anesthesia.  My attending and I gave the patient just enough medication to put her to sleep, then I ducked under the drape to intubate.

The rest of the case went as smoothly as a cardiac case ever goes.  The CT surgeon found the LAD defect and repaired it; he also found a puncture in the internal mammary artery that required surgical repair.  The patient pulled through and was safely tucked into an ICU bed by dinnertime.

As I left the hospital that evening, I reflected on what I had done.  The cardiologist had identified his patient's life-threatening cardiac tamponade and relieved it, but her rate of blood loss would have caused exsanguination had I not become concerned and started autotransfusing her own blood back to her.  What I had done was a very simple thing, but it turned out to be a vital component of the patient's management and resuscitation.  It even earned me a solid round of attaboys from the cardiologist, the CT surgeon, and my attending.

It's like I always tell the junior residents: a calm demeanor, tape, and the proper application of elbow grease.

Temporary paralysis

A lot of people think they're allergic to morphine.  They're usually not really allergic, as I've mentioned previously; generally, they just have the side effects common to opioids, things like nausea, itching, sedation, and constipation.  Even respiratory depression (or "I stopped breathing," as patients usually phrase it) is not necessarily an allergic reaction, since opioids are respiratory depressants and "I stopped breathing" usually just means "I got too much."  ("I stopped breathing because my airway got all swelled up" is a different story, however.)

I was doing a preop evaluation of a pleasant 45-year-old woman who was going for brain surgery.  She'd been worked up for headaches and was found to have an intracranial aneurysm that required clipping, both for improvement of her headaches and to prevent rupture later in life.  She was in shape and healthy, so we were breezing quickly through the preop form when I got to the "Allergies" section.

"Ma'am, are you allergic to any foods or medications?" I asked her.

"Yes, I'm allergic to morphine," was the reply.

"Mm-hmm," I said, making a note, "and what happens when you get morphine?"

"I get temporary lower body paralysis."

I stopped and looked up from my notes.  Temporary lower body paralysis as a reaction to morphine?  Not something you hear every day.

"Tell me more about what happened," I said.

"Well, I last had morphine about 20 years ago," she told me.  "Pretty soon after I got it, I couldn't move my legs anymore, and that lasted for a couple of hours."

Weird, I thought.  "Any problems with your arms, or with breathing?"

"No, just my legs."

"Any itching, rash, or swelling of your lips, tongue, or throat?"

"No."

"And what was the context?  Why were they giving you morphine?"

"I was having a c-section for my first child," she replied.

A light clicked on in my mind.  I had a good idea what had happened, and it was no allergy.  I still had to ask some more questions to be sure.  "Ma'am, did you have your c-section awake?  Or did they put you to sleep and put a breathing tube in?"

"I was awake.  They just put a little shot in my back so I didn't have to go to sleep."

I'd figured it out by this point.  The patient had received intrathecal anesthesia (otherwise known as a spinal) for her c-section.  A typical c-section spinal dose consists of a long-acting local anesthetic combined with short- and long-acting opioids.  The local anesthetic numbs the nerve roots destined for the lower extremities, depriving the legs of both sensation and movement.  This lasts for about 90 minutes or so, at which point sensation and movement should both return.  I asked the patient if that's what she experienced and she said yes.

"Ma'am, from what you've told me it doesn't sound like you had an allergic reaction to morphine at all," I told her.  "It sounds like they did a spinal for your c-section and it did exactly what it was supposed to do."

The patient thought for a moment, then asked, "So, that temporary paralysis in my legs was normal?  It was expected?"

"Yes, from what you've told me," I answered.

The woman was shocked.  "I can't believe that no other doctor told me that!" she exclaimed.  "I've spent the last 20 years thinking I was allergic to morphine!"

I was a bit surprised about that, too.  "Has any doctor ever said, 'You're allergic to morphine?'"

"No," the patient said slowly, "they told me the spinal would take away the feeling but they didn't say anything about movement.  I guess I just assumed that was a problem, and my sister said it was probably the morphine."

"Is your sister medical?"

"No," the patient replied, blushing, "but I've told lots of doctors I was allergic, and none of them ever told me what you just did!"  It was clear she was a bit embarrassed.

"Well, I don't think you're allergic, ma'am," I told her.  "I think everything worked just like it was supposed to.  I'm a bit disappointed that no other doctor explained this to you."

I made appropriate documentation in the patient's chart regarding the nature of the "allergy," and the rest of the interview went smoothly.  I was, and still am, surprised that no physician had availed him or herself of the opportunity to educate this patient on the nature of her "allergy."  Or maybe someone had told her, and she just hadn't listened.  That happens very often, as well.  In any event, I felt I had done my due diligence in patient education.

The patient had her surgery the next day.  She received morphine and nothing happened to her.

Another medical mystery solved, and another life saved.  Sort of.

¡Al infinito y más allá!

During October of my CA-1 year, I found myself working on a Saturday as the senior resident on duty in the SICU, accompanied by a very smart and hardworking surgery intern.  Our entire team had signed out and left the hospital by 11 am, and naturally that's when all hell broke loose.  My intern and I split up, he to handle the SICU pager and the needs of all the existing patients and I to receive a new admission being brought up by the trauma team.

My new patient looked terrible.  He was an old Hispanic man with two chest tubes on the right and one on the left, a Foley catheter, and two large-bore IVs.  He looked pale and was clearly not with the program mentally, whether as a result of his trauma or from preexisting dementia I couldn't say.  He had a non-rebreather face mask delivering 10 L/min oxygen and soft restraints on all four extremities.

The report I received from the trauma team was less than satisfactory.  "This is a 94-year-old goner," I was told.  "He wrecked his car on the interstate, got those right-sided chest tubes at an outside hospital, then got turfed here where we put in the left chest tube.  Massive hemothorax on both sides.  He's down about 2.5 liters of blood now.  He's DNR/DNI."  And before I could get my bearings to ask any more questions, the trauma team had fled the SICU and left me alone with the patient.

I've been a part of many major trauma resuscitations in the OR, but this was something different.  I was used to a full-court press in the OR: pressors, blood products, the works.  What was I allowed to do in a patient who was DNR/DNI?  I knew I couldn't shock him or run a code on him, but could I give blood?  What about low doses of pressors?

The patient was mentally in no state to answer for himself and his family hadn't arrived yet, so I did the only thing I felt I could safely do: I ordered the nurse to blast him with a full liter of Voluven.  His wrists were both scored with multiple attempts at arterial line placement, so I prepped his groin and started a femoral a-line under ultrasound guidance.  His pressure was very low and his heart rate was very high, but he was seeming to respond to the volume we were giving him.  I ordered another 500 ml of Voluven, then started a subclavian central line to help guide our volume repletion.

While all this was going on, my intern was handling the issues with the rest of the SICU service.  He occasionally poked his head in to ask a question or clear a decision with me, but the SICU pager never left him alone for more than a few minutes.

In the midst of this perfect storm, the patient's daughter arrived.  The patient didn't look very good but was holding his own (barely), so I stepped out to speak with his daughter.  "Mrs. Martinez," I said, "your father was in a bad car accident and it looks like he lost a lot of blood.  I understand he's DNR/DNI and I want to respect that, but his advance directive is pretty vague about what I can and cannot do.  I need to know if I can give him blood products."

The man's daughter was teary-eyed as she looked around the SICU, overwhelmed by the foreign surroundings and the persistent feeling of sickness and death that permeates the place.  "I don't know," she answered.  "I have power of attorney, but I need to talk to my brother and sister to answer that."

"I understand.  I recommend calling them now, though, so we can press forward with treatment if it's OK."

His daughter took her leave to call her siblings and I checked up on my intern.  Things were beginning to settle down, my intern had handled everything perfectly, and I said a quick prayer of thanks for being paired with such a capable junior.

After a few minutes, Mrs. Martinez came back.  "Doctor," she said, "we all agree that you can give our dad blood products if, in your professional judgment, it will save his life.  But please don't intubate him, and don't give him blood pressure medicines, and don't shock him or do CPR.  I'll sign whatever paperwork you need for this."

I thanked her for her prompt response and asked a nurse to draft up the necessary forms, then I called the blood bank and asked them to expedite the blood matching process.  In short order, the blood began to arrive and the nurse and I started transfusing the patient.

The rest of the night was a blur.  I spent nearly all of it at the patient's bedside.  The patient's nurse and I used labs, vital signs, and in/out volume measurements to guide our efforts as we replaced red blood cells and clotting factors and fluid that had been lost.  We had no idea whether the patient had healthy kidneys, so we were somewhat conservative in our volume replacement -- conservative enough that my attending ripped me for "under-resuscitating" the patient the next morning on rounds.  As I always do when taking crap while 29 sleepless hours into a 30 hour shift, I smiled, said "Yes, sir," and thought about going home and to bed.

Over the next 36 hours, the patient showed significant improvement.  His mental status recovered and he showed himself to be sharp as a tack, with a quick wit and a great sense of humor.  His family was ecstatic and humble and began to refer to me as "Dad's doctor," even though I was a relatively junior member of a large team.  I spent a lot of time with that patient over the next week, getting to know him and his children and his grandchildren and his great-grandchildren, who hugged me as if I were a longtime family friend.  They asked about my kids, and I told them that my son would be turning three on the last day of my SICU rotation.

The patient did remarkably well.  He was out of bed and working with the physical therapists within days of his crash, and by a week out he was ready for transfer to a rehab facility.  I stopped by to say good-bye on his last day in the SICU, the day before my son's birthday.  As they often are, the farewell was bittersweet: a terrific patient was about to leave my life, but he was able to because my ministrations had helped make him whole.  He shook my hand and thanked me for helping him get more time on Earth to spend with his family.

When I went to shake his daughter's hand, she stood and embraced me, tears in her eyes.  "You've been a guardian angel to my dad, Doctor," she told me.  "You've saved his life."  Then, reaching down, she picked up a large gift bag.  She smiled as she pushed it into my hand.  "I know you can't accept gifts from family members or patients, but you can't stop the Martinez family from buying a birthday present for your little boy!  You take this to him, or I'll follow you to your house and give it to him myself!"  And then she hugged me again.

My son opened his birthday presents the next day.  The Martinez family had given him a Buzz Lightyear toy, one that has phrases in English and Spanish.  My boy fell in love with it.

And now, every time I hear "Buzz Lightyear a tu servicio!" I remember that long, sleepless SICU night, and how I helped save the life of a 94-year-old goner.

Mortality

They say you never forget the first time.

The EMS call came in around 7:30 pm: "48-year-old female, collapsed at home in front of witnesses, arriving by ambulance in 10 minutes, CPR in progress."  The last three words meant this was no simple blackout or seizure, and we were jolted into action.  The trauma bay was fully staffed and ready to receive the patient within moments.

The tension hung heavy in the air, as it always does when awaiting the arrival of a catastrophically ill patient.  Several ED residents donned surgical gowns and face shields, and we all put on gloves.

And then we waited.  Nobody said anything; there was nothing to be said.  This was an outstanding Emergency Department that was used to handling critically ill and injured patients, and everybody knew the correct place to be.  I wasn't quite sure how I could help as a fourth-year med student, so I looked at my resident and raised my eyebrows; he pointed at a spot in the trauma bay and I went to it.

After an eternity, we heard an ambulance's siren, faintly at first, then gaining strength as it approached.  At the end of the hallway, the ambulance bay doors flew open, chilling us with a blast of cold November wind.  A gurney appeared along with a pair of EMTs, one squeezing an AMBU bag connected to an endotracheal tube, the other straddling the patient and performing chest compressions.  Several nurses quickly converged on them, and together they ran down the hallway toward the waiting trauma team.

Within seconds, the gurney was beside the trauma bay bed; then we all reached to take hold of the backboard; then someone shouted "One, two, three!" and we all lifted.  The senior ED resident, only seven months from completing his residency, immediately took charge, calling people by name and giving assignments: "Keep bagging!  Resume chest compressions!  Get her on our monitors!  Hook up the defibrillator!  IVs!  A-line!  Drugs!  Record!"  I was assigned to deliver extra IV and a-line supplies to the appropriate team members, and to take a turn performing chest compressions when others became tired.

Most of the code became a blur after that.  I rotated through my turns doing chest compressions, feeling the unsettling scrape of cartilage against bone under my hands, feeling the sickening crack as I managed to break a rib that had miraculously remained intact through CPR.  I was vaguely aware of the EMTs giving what little information they had to the attending and senior resident.  The senior resident called for epinephrine and it was given.  Sometimes he asked for vasopressin.  Sometimes we stopped doing chest compressions so the defibrillator could evaluate the patient's heart rhythm.  It was PEA.  PEA isn't a shockable rhythm.  We resumed chest compressions.

Time dilates during a crisis.  For what felt like an hour, we did CPR, gave drugs, and checked the defibrillator.  The senior resident was running the code perfectly, so the attending excused himself to go talk to the family for a few minutes.  He asked me to join him.  I looked at the clock as we left the trauma bay.  The "hour" of CPR had only taken fifteen minutes.

We went to the counseling room where the patient's family had been brought.  I stood back and watched as my attending spoke with the husband.  He was a big man with a full beard; he looked like a man who loved to ride motorcycles, drink beer, and dote on his daughters and granddaughters.  He tearfully told us that his wife was a home hospice patient, but he wasn't able to tell us what she was sick with.  He told us about a couple medication allergies.  Then he pointed at my attending and said, "Doc, don't you pull that plug unless I tell you to!  Don't pull the plug unless you hear those words come out of my mouth!"

How do you respond to such an order?  No doctor wants to see a patient die, but everyone's story ends the same way.  One last breath.  One last heartbeat.  And then nothing.

The attending was as gentle as he could be.  He told the grief-stricken husband and family that there was no plug to pull since their wife and mother wasn't on a life-support machine.  He told them that her heart wasn't beating and his team was trying to start it again.  He told them we'd do what we could, but we couldn't keep going forever.

I followed my attending back to the trauma bay.  Nothing had changed there.

"Epinephrine, one milligram!" called the senior resident.

More chest compressions.  Then another defibrillator evaluation.

"V-fib!" announced another resident.

"Everybody get clear!  Shock, 200 Joules!"

"Charging, 200 Joules.  Everybody clear?  Shocking in three, two, one!"

The wiry-thin patient jumped just a little from the shock.  Nothing like what you see on TV.

"Resume chest compressions!" ordered the senior resident.

Several more rounds of CPR.  Several more shocks.  Coarse v-fib became fine v-fib, then the heart monitor went flat.

"Call it?" asked the senior resident.

"Call it," confirmed the attending.

"Time of death, 2025."

We all stepped back from the patient, sweat-drenched and exhausted.  Then, unexpectedly, the pulse oximeter gave a lone beep.  We looked at the monitor.

"...no way..." breathed the senior resident.

Sinus bradycardia.

Someone felt the patient's carotid artery.  "Pulse is very weak and thready...fading...fading...gone."

"Resume chest compressions!" ordered the senior resident.

And so we started the code again.  More chest compressions.  More epinephrine.  Defibrillator evaluation showed PEA.  Several more rounds of compressions and meds.  Then coarse v-fib.  A shock.  Compressions.  Drugs.  Fine v-fib.  A shock.  Compressions.  Drugs.  A flat line on the monitor.

"That sinus brady was probably because we pistol-whipped her heart with so much epi," the attending opined.  "Call it."

The senior resident's dejection at this defeat was clear.  "Time of death, 2047."

We left the trauma bay in silence, taking off our protective gear as we went.  Someone turned off the monitor.

A few nurses and techs who hadn't been in the code went into the trauma bay to clean up.  They cleaned the vomit and blood from the patient's face, and extubated her, and closed her eyes.  They got clean sheets and covered her to the neck.

My shift ended at 9 o'clock that night, a blessing after my first time watching another person depart this life.  But even though my work was done, I couldn't leave.  Instead, I went to a quiet hallway behind the ED.  I stood there for nearly thirty minutes watching the snow gently falling outside, placing my hands on the glass just so I could feel the cold.  Though it may seem strange, I didn't think about the patient or the experiences of the evening.  I just needed solitude.  I needed to consider my own mortality.  I needed to turn my thoughts toward God.

And then I felt the quiet after the storm, and I knew it was time to go home.  I went to the resident workroom and got my coat and backpack.

As I passed the trauma bay, I caught a glimpse of a young man about my own age, tears streaming down his face as he grieved for his mother, a young lady encircling him with her arms as she wept with him.  I averted my eyes and kept walking.  In a moment of such desperate grief, even the mere gaze of a stranger is hateful.

It's true what they say.  You never forget the first time.