It was a routine morning and we were getting ready for the routine surgical list. I just stepped to the neurosurgical ICU to see a patient who was admitted early morning with multiple trauma and had been referred to me for chest injury. He was being ventilated and needed a fair bit of support to maintain his respiratory parameters. His neurological status seemed to be borderline and he had fracture involving ribs, collar bone (clavicle) and pelvis and femur. His lung injury seemed bad as well. Usually these injuries recover on their own but they do need prolonged support with ventilator. After speaking to his relative about the seriousness of the injuries and the fact there was little for me to add on anything at this stage to the treatment of the intensivist I made my way back to my OT. I did warn them that next 24-48 hours were crucial and that once he crosses that recovery will be slow and prolonged.
Later on in the day he seemed to deteriorate and the intensivist found him difficult to ventilate. He was unable to maintain his gas exchange despite full ventilator settings. His carbon dioxide levels were rising up dangerously. There’ was only one option available to support his failing lungs and that too was fraught with dangers. But as he was a young lad who had been married only last year we decided to offer this option to the family. ECMO is a machine which works as the artificial lungs and heart for a patient like this. It needs blood to be kept very thin and that increases the risk of bleeding in cases of trauma which can cause major internal bleeding and death.
As there was no option but to accept the risks family decided to go ahead. We were successful in putting the patient on ECMO. His gas exchange immediately improved and he stabilized. Rest of the injuries needed operative treatment but as he was on blood thinners these had to be postponed. Only if there was a chance that he would survive, it would make sense in undergoing these surgeries. After 3-4 days his neurological status improved and he became fully awake which kept our hope alive. By 10th day his lungs had cleared up completely and we were able to remove the ECMO. In next 24 hours his hemoglobin levels dropped significantly and we were not sure where would he be loosing the blood. Luckily for us as his blood thinners were off we hoped his bleeding would not worsen.. Then his urine output stopped and an ultrasound confirmed that he had bleed behind his pelvic bone from the fracture site and this blood created compression on the bladder. He went to surgery for evacuation of blood clots ( hematoma)and this solved his problem. Urine output recovered and all other fracture fixations` were done. After staying in hospital for one month and efforts of team of doctors he was finally sent home and has now recovered completely.
Sometimes modern technology with back up of experts and infrastructure with a blind faith of the family in the treating team leads to saving precious lives.
- Dr. Sandeep Agarwala
Sr. Consultant Cardio-thoracic Surgery