Five Patients - Crichton Michael - Страница 16
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As they began work, they found that the crush injury, with its hemorrhage and swelling of tissues, made identification of structures difficult. Five minutes into the operation, the radial artery was accidentally nicked. A fine, thin stream of blood spurted up in a foot-long arc. This was quickly clamped, and Moncure sewed it up with a small needle, perhaps no larger than twice the size of a typewriter parenthesis mark, and the operation proceeded. Moncure isolated the radial artery for a distance of several inches through the wrist. Everyone commented on the fact that pulsations through the artery were not as strong as they would like. The artery was flushed with heparin to prevent clotting further along its course in the hand.
At 7:20, Dr. Leslie Ottinger, another surgeon, entered the operating room. He had been working next door in OR 8 for six hours, repairing a crush injury to a man's thigh. Moncure, without looking up, said to Ottinger: "Were your vessels intact?"
"No," Ottinger said. "The femoral artery and vein were completely crushed. They were separated by three centimeters." "How's he doing now?" "Fine," Ottinger said, "if he stays open." He watched the dissection of the hand for some moments. "You find the radial artery yet?" "We nicked it," Moncure said. "Well, that's a good way to find it," Ottinger said, and left.
As the operation progressed, Moncure noted that the surgical field was more bloody. He felt the radial artery and concluded that it was pulsating more fully now.
By eight o'clock, the contrast between the area of surgical dissection and the area of crush injury was clear. One was clean and smooth, nicely exposed, bleeding very little; the other was mashed and oozing blood. Moncure, still working, glanced up at the clock and said: "Ottinger and I had a squash game for eight o'clock. We both ended up here. That'll teach us."
The operation itself proceeded slowly, impeded by the difficulty of identifying structures within the injured area. When damaged, a tendon, vein, and nerve can all look remarkably alike, but identification must be made with certainty. Nearly any vein in the body can be cut without consequence; to cut a tendon is an irritation, but not irreparable; to cut an important nerve is a disaster of major proportions.
Eventually all the structures were identified. All were found to be intact except for the ulnar artery, which was completely torn. The muscular coat of the artery was in spasm, pinching it off; the ends were clipped for the time being, and Chandler took over to begin work on the bones.
His first decision was to shorten the left arm by half an inch. This was necessary because there was a fragment missing from the ulna, and both radius and ulna had to be the same length. Also, shortening would make repair of tendons easier. He pointed out that this shortening would not be noticeable to the patient or anybody looking at him.
He began by filing the ends of the radius smooth and then joining them together with a vitalium plate, made of an alloy of cobalt, chromium, and molybdenum. It is electrically neutral and well tolerated by bone and the tissues around it. Screwing the plate onto the bone was difficult; it was not completed until 10:30.
Meanwhile, the anesthetist had been making some changes. "The axillary block has worn off by now," he said. "So we're supplementing the nitrous oxide with halothane in low concentrations. If he needs more for pain, we'll raise the halo-thane." He indicated that he could judge the need for anesthetic by watching the patient who, while not waking up, would become restless and would breathe irregularly if he was "too light."
"The idea," he said, "is to give the minimal anesthetic necessary to do the job, and to give it in such a way that the patient wakes up as soon as possible after the operation."
After Chandler repaired the radius, Moncure resumed vascular and soft-tissue reconstruction. He first re-examined the radial artery and decided it was not flowing as well as it should, as judged by squeezing the artery wall and feeling the pulsations. To make certain it was clear, he called for a small Fogarty catheter. This is a small, flexible tube with an inflatable rubber bulb at one tip. From the opposite end, water can be injected into the tube, and the bulb will expand. Thus the catheter can be inserted down an artery, and the bulb inflated within the artery. It can then be drawn back while inflated, and in doing so, it will clean out the inner wall of the artery, removing clots and other obstructions.
The Fogarty catheter is a relatively new device, named for its inventor, a surgeon at Stanford Medical Center. The discussion that ensued is typical of medicine in the modern day. So many developments and products are becoming available that it is difficult for anyone to keep track.
Moncure: "Get me the smallest Fogarty you have."
The circulating nurse came back with one. "This is a number four."
Moncure: "Let's have a look at it." He removed it from its plastic container; it looked too large. "Are you sure you haven't got something smaller?"
Scrub nurse to circulating nurse: "I know we have a six, at least."
"But a six is larger than a four," the circulating nurse said. She said it hesitantly, since numbers to designate sizes do not always run the same way. For instance, urinary catheters and nasogastric tubes run in proportion to size-a number fourteen is larger than a number twelve. But needles and sutures run in the opposite direction: an eighteen is much larger than a twenty-one needle. "Well, see if there's something smaller." It turned out there wasn't. Moncure meantime had made a small cut in the artery wall, and had found he could slip in the number four Fogarty without difficulty. He inflated the bulb, drew back, and found that the subsequent pulse was much improved. He sewed the cut shut, and felt the pulse. "Bounding now," he said.
He directed his attention to the ulnar artery, which had been completely severed by the injury. The ulnar was smaller than the radial artery; it was about the size of a pencil lead. As Moncure began to sew the ends together with fine sutures, he said, "Microsurgery. Watchmaking." It was now 11:30. He sewed it quite quickly, and the remainder of the operation, which dealt with larger structures, went rapidly. The tendons that had been torn were resewn. A heavy pin was run down the hollow interior of the ulna. By 12:30, the surgeons began to close.
It had been known from the outset that the wound area could not be completely closed. The tissues were damaged and swollen; to pull the skin tight across it would compress the arteries and cut off circulation to the hand, negating all the efforts of surgery. The incision was therefore only partially closed, with an area of the inner wrist left open. This area was expected to close by itself, to a degree, and to scar over for the remainder; after four or five days, they would reevaluate the area to consider skin grafting. The surgeon's major concern was infection. It was decided to continue the patient on cephalothin.
The operation was finished at one in the morning. The patient awoke in the operating room and was taken to the recovery room. For the first twenty-four hours, he was kept heavily sedated, but by the third day his pain was considerably less. Two weeks later he was discharged from the hospital. Two months later, on an office visit, Moncure found that the patient had essentially full function and sensation in the nearly severed hand.
The growth of modern surgery within the hospital is chiefly attributable to three factors. The first is the discovery of anesthesia. The second is the introduction of aseptic techniques. And the third, much more recent, is the improved medical understanding of the patient, with attendant improvements in pre-operative and, especially, postoperative care.
Consider anesthesia first. One hundred and three years before Peter Luchesi's hand was sewn back on, John C. Warren wrote: "Surgery has ceased to be the spectacular occupation it once was." It is impossible to miss the regret in his words, but he did not mean it regretfully, for he was talking about the difference anesthesia had made to surgery.
It is hard to imagine how ghastly, dangerous, and hasty surgery was before anesthesia. In Warren's own recollection:
In the case of amputation, it was the custom to bring the patient into the operating room and place him upon the table. [The surgeon] would stand with his hands behind his back and would say to the patient, "Will you have your leg off, or will you not have it off?" If the patient lost courage and said "No," he was at once carried back to his bed in the ward. If, however, he said "Yes," he was immediately taken firmly in hand by a number of strong assistants and the operation went on regardless of whatever he might say thereafter.
Relief from pain was not the only benefit of anesthesia. Equally important was muscular relaxation, which prior to ether was produced as follows: "In the case of a dislocated hip, where it was necessary to effect complete muscular relaxation, an enema of tobacco was freely administered, and while the victim was reduced to the last stages of collapse from nicotine poisoning the dislocated femur was forced back into its place."
One might expect this deplorable state of affairs would lead surgeons to search for ways to kill pain and to be constantly alert for new drugs that might accomplish the job. But in fact this did not happen: pain-killing drugs were known for forty years before they were applied to surgery. If, as Poincare says, discovery favors the prepared mind, doctors must be counted strangely unprepared. Briefly, the story is this:
Nitrous oxide was isolated by the English chemist Joseph Priestly in 1772. Around 1800, another Englishman, Humphrey Davy, experimented with the gas, noted its exhilarating and pain-killing properties and suggested it might be used in surgery. The suggestion was ignored. Instead, "laughing gas" became a popular form of amusement on both sides of the Atlantic. In 1818, ether was found to have the same effects as nitrous oxide. Soon thereafter, "ether frolics" came into vogue, especially among medical students and house officers-indeed, a whole generation of young doctors toyed with immortality, but missed the point. The observation was repeatedly made that one could bruise himself while under ether and have no recollection of the cause later, but no one connected the phenomenon to surgical applications. The blindness of these young men is sobering. (It also makes one think more highly of Alexander Fleming, whose culture dishes, contaminated with mold, might have been thrown out. One wonders how many hundreds of researchers before him had seen penicillin-producing molds, and had attached no significance to them.)
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