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Surgical notes: Bleeding always stops eventually

It was Wednesday night last week that I had my first night of trauma call. Instead of my normal quota of one pager going off no less than once per day (usually with breaking news on our lecture schedule, but often to find my team or receive tasks), I was carrying a second: the trauma pager. It's not so much a pager to answer as it is an alert to begin making your way to the ER to admit an incoming trauma patient.

I paged the resident on call for trauma service, and gave him my own personal pager number as well in case he needed to reach me for anything else. That was at 5 pm. It was almost 6 pm when I was paged and informed there was an in-house patient headed to the OR with an upper GI bleed. The surgical team was informed I would be on my way to help out, and I was to head to suite 15. I hung up and left the lounge to head towards the OR.

I scrubbed before I walked into the OR suite, hat and mask in place as well, and was greeted by the scrub nurse who asked for my glove size as she gowned me, and once all was in place I stepped up beside the patient with the attending just as the incision was being made vertically down the abdominal wall. The abdomen was already beginning to look distended, and after cutting through the muscle fascia the small bowel swelled into view.

I realize most people have never seen the site of a human's intestines laid open, much less know the site of intestines that are swollen like a water balloon with blood, but that was the situation presenting to us. On top of the large amount of distended bowel to deal with, the abdominal cavity was a basin full of blood. Multiple suction tubes were prepped and inserted to drain the abdomen so that the anatomy could be visualized. As the resident and attending discussed the patient I learned he was having an upper GI bleed, somewhere around the duodenum (the first part of the small intestine just as you exit the stomach). After much of the blood in the abdomen was drained away, the surgeons cut through the stomach and duodenum in an attempt to find the bleed. Blood continued to pour from the bowel, and no definite site of bleeding (at least not in proportion to the amount of bleeding occuring) was found. Blood continued to pool in the abdomen faster than I was able to clear it with the suction tubes, and many times I had to resort to using my hands to scoop large preformed clot from the cavity.

Eventially the bleeding was enough of a problem with working that a vascular clamp was placed across the aorta, above the celiac trunk. For those who aren't familiar with anatomy, the celiac trunk is the first artery to come off the aorta after it enters the abdomen from the heart. The celiac trunk and every subsequent artery provides every organ and limb below the lungs with blood. Essentially, we cut off the blood to half his body.

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