X-Message-Number: 602
From: Keith Henson
Subject: Transport of Patient A-1312 (Part 2)
[ Part 2 of 2 - KQB ]
The Transport of Patient A-1312
by H. Keith Henson
In addition to the transport team, we had several helpers available to
move Dennis from the bed to the PIB. Dennis was a large guy (215 lb.),
and while he was wasted in the upper body, he was *really* edematous in
the legs, with a massive abdomen from his cancer-invaded liver. Moving a
person of that size can be nearly impossible. We did it by the sheet-
pickup method, and lots of helpers; I seem to remember 4 on each side.
(A week later, at a memorial at our patient's house an old friend of mine
repeated the aphorism that a friend is someone you call to help you move,
and that a *real* friend is someone you call to help move a body. We had
lots of real friends that day.) Moves of this type need to be carefully
planned out in advance, and everyone told exactly how it is going to be
done. In this case, he went out over the end of his bed, and back over
the end of the Pizer tank. I removed the IV pole from the MALSS so it
would not be in the way, and stuck it back on when they had him placed.
The HLR was on Dennis in about 2.2 min from the time he was pronounced.
Afterwards Leonard recommended that we measure our patients and adjust
the HLR base to fit. We had significant problems with the HLR plunger
moving out of position during use--partly because the massive liver and
ascites made the chest slope toward the neck. As a result, the plunger
walked upwards and twisted sideways, requiring frequent readjustment.
In a matter of seconds, ice and water were dumped into the portable ice
bath on top of the MALSS cart; within 2.5 minutes of his being pronounced
the HLR was started. The transport medicines were administrated through
an indwelling Quinton catheter which had been left in place for us.
Shortly after we started the HLR, the hose blew off the plunger. I put a
cable tie on it after Leonard stuck the hose back on. Arel had trouble
keeping the airway open, but she learned that when she could hear a death
rattle the end-tidal CO2 monitor showed good oxygenation, and the only
way she could keep the airway open was by hyperextending the neck. This
had to be done regularly to avoid poor ventilation. After a couple of
these adjustments, a lap pad was rolled up and placed under the patient's
neck as a bolster. To augment Arel's suggestion that a bolster should be
included with the ice bath, Tanya made a better suggestion of an
adjustable strap on the PIB to correctly hyperextend the neck for better
ventilation.
It took a lot of strength from Joe or Leonard to keep the mask sealed to
the patient's face because of facial wasting (which was also the case
with Arlene Fried, whom we stabilized two years ago--taping the mask on
didn't work because Arel had failed to put the tape all the way around
the head, and because the water soaked it off, but an elastic or Velcro
strap such as that used earlier on the patient's oxygen mask might have
helped). We should have intubated him, but what we did worked OK, and
Mike, the only person who could have done it was otherwise fully
occupied. (We discovered during the glycerol perfusion the next day that
the patient's head had been bruised, probably by being pressed against
ice in the bottom of the bath because of the pressure needed to seal the
mask.)
About an hour into the stabilization the first cylinder ran out of
oxygen. There was a quick change of cylinders, and everyone vowed next
time to put a regulator on the second cylinder *before* the first one
runs out.
While Leonard, Joe, and Arel were busy at the head end, Naomi was
injecting the transport meds. It was not until after the suspension that
Naomi realized that she had forgotten to continue to add medications
after the initial boluses and continuous infusions were set up. During
this Mike and I were doing a cutdown. (Tanya was taking notes, and Carlos
was video taping.) Dennis was very edematous, and his vessels were deep,
over an inch. We used up every gauze sponge we had in the kit and the
ambulance trying to keep the operating field dry, and had use for the
suction when we had a bleed. The night before one of the nurses and Mike
had spent a lot of time trying to find a pulse from these vessels, and
had failed. We tried on the side which had been used for chemotherapy
infusions, and gave up. (In retrospect, we almost certainly did not go
deep enough). We cut into the other side, and eventually located a
vessel with a clot in it, but no artery. After enlarging the incision
both directions, and cutting down to muscle in some spots, we finally
found the femoral vein. Cutting through tissue that edematous was a real
problem.
Once we exposed the vessels, Mike had to tie off a number of small
branches to get down to the femoral artery. After tying off the distal
ends, ligating the vessels and putting a small clamp on the proximal end,
Mike clipped partway into the vessels (one at a time) with scissors. He
cut the vein first, and then the artery. The cannulas went in with each
of us holding one side of the vein or artery. I managed to screw up and
backed out the arterial cannula in error.
Cannulas need to be *securely* tied down, because having one come out is
very, very hard on the patient. (I.e., in about a minute all their blood
is gone.) Operating an ECMO circuit is tricky; for one thing, you have
to be sure to get all the bubbles out of the circuit where the tubing
splices into the cannulas. This is done by filling the end of the tubes
and the cannulas from a syringe filled with saline. When we finally did
get things hooked up, it was a relief to see that the arterial blood, and
even the venous blood was well oxygenated. Hats off to the head-end
crew!
The nurse who pronounced stayed and helped as scrub nurse. It is
impossible to say enough good things about her. She was a welcome and
valuable asset to Mike. (I was green as grass as a surgical assistant).
When we got the ECMO circuit hooked up, the patient's temperature was
still rather high. He went on bypass after an hour and 45 minutes with
an arterial temperature of 23.2 deg. C. (Far too much time to do a
cutdown, but about the same as Arlene because of the time it took to
transport her to a mortuary for the cutdown and washout.) Arlene's
smaller mass had cooled much further in that time. Bypass greatly
increased the cooling rate, though we could have used a larger heat
exchanger.
During the surgery I noticed a few problems with the squid (ice water
circulator). Dennis, being such a large guy, took up the entire tank
from side to side. This caused the water to pile up on the head end, and
not flow fast enough to the foot end where the pump intake was located,
so the pump tended to suck air while the head end of the tank flooded.
Two lengths of 2-inch plastic pipe about 4.5 foot long placed in the
bottom of the tank would help get the water back to the foot of the tank
and the pump.
The heat sink for the blood heat exchanger is water in the Pizer tank.
This works, but you need to watch and be sure there is plenty of ice
where the water is flowing. A lot of ice was melted between the intake
and outlets. I suspect that the heat transfer water was not as cold as
it could have been, i.e., it was above 0 degrees C part of the time.
Another improvement for getting heat out of the patient would be to put a
grid of small pipes in the bottom of the PIB, and draw or release water
through them. This would prevent blocking the heat flow out of the
patient's back by pressure on the bottom of the tank. Large people just
cool slowly from the surface. By the time we had completed the cutdown
on Arlene Fried she was at the washout temperature. It took about the
same time to get Dennis hooked up, but it took considerable additional
time recirculating blood to get him down to washout temperature. It just
takes longer for a person with three times Arlene's weight.
When the patient was cooled to about 12 degrees, Mike started dumping
treated Viaspan into the bag reservoir on the MALSS cart, and opened the
venous return line to begin the Viaspan flush. He had hooked up an
additional large-bore dump, but the special Viaspan spike broke off in
the first bag. We jury-rigged an IV spike replacement (which leaked some
Viaspan on the floor) and used a small-gauge port as well. The Viaspan
flow rate was very slow, and Mike had to keep turning the pump on and
off. At one point he got distracted, and air was sucked into the system,
but fortunately none got into the patient. A cross-connect line at the
patient end would have been a blessing to get the bubbles back in the
reservoir. In spite of all our troubles, which included blowing the
tubing off the oxygenator and putting more Viaspan on the plastic sheet,
we got all but one or two of the Viaspan bags into the patient. Mike
saved these for buffer for the trip to Riverside.
Even with all the cold Viaspan, the patient was still at a little higher
temperature (4.1 deg C) than desirable for transport, but we had to go.
Fortunately we still had plenty of people around, because we used them to
move the MALSS cart down a step, and take much of the weight off the
overloaded wheels as we moved it to the ambulance. (The MALSS cart
started life as a *gurney*.) We bailed out the PIB, and removed much of
the ice for the short move to the ambulance, still, the MALSS cart and
Dennis weighed about 800 pounds. The lift gate on the ambulance worked
great; whatever was paid for it, it was well worth it.
During the transfer to the ambulance and for almost the entire drive to
Riverside, Dennis was maintained on low-flow circulation. The MALSS cart
has two large deep-cycle batteries and a charger built in. We kept the
cart hooked up to AC power until we left the house. That left enough
power in the batteries to run the cart for many hours. Dennis arrived
with no rigor, an indication of adequate metabolic support all the way.
We (Mike, Carlos, Tanya, Arel, Keith, and Naomi) managed to get on the
road at 9:16 pm. I drove the ambulance from Dennis' house to Stockton.
After getting out of the Bay Area we hit a solid wall of fog. What with
the lack of sleep, I was fading and felt my competence to drive fast into
dense fog was lacking, so I swapped with Carlos and drove the van
(following lights on the ambulance) for a while. At a gas stop Arel took
over driving, and she lost the ambulance in dense fog. (The unholy rush
down Interstate 5 was to get the patient to Alcor before the contract
surgeon had to leave--although Arel didn't know this.) We drove on a for
a while then swapped again after picking up gas at Kettleman City. The
fog was so dense at Kettleman City that you could only see one of the gas
stations at a time. I made it almost to the Grapevine before deciding
that going any further was going to result in a wrecked van. We pulled
off the road, called Alcor from a phone, and got a nap between 4 and 5
am. The cold woke us up and we reached Alcor close to 8 am, an hour and
a half behind the ambulance, and just as Saul was rushing the contract
surgeon to the airport. He had only managed to get part of the perfusion
"plumbing" in place, but Mike was able to take over and complete the job.
I know we may have to make do with contract personnel, but I sure am not
happy about it. Arel had the shakes from lack of sleep and sheer terror,
and since there were plenty of OR people available, she appropriated one
of the beds in the crew room for the next three hours.
Wasted as I was, I felt I could not go to sleep, so I scrubbed and dried
the PIB on the MALSS cart, and got the cooling setup together and down to
temperature. Later I had to get into scrubs and help Mike, Hugh, and
Arel with the cephalic isolation.
During the operation Mike took over he had a serious problem with the
aorta's tearing, but he was able to clamp off the tear. How well our
patient had been supported was apparent from the complete lack of brain
swelling. All three of the last well-supported patients have lost a
profuse amount of fluid from the bur hole (used to see how the brain is
perfusing.) Almost the entire perfusion circuit withdrawal amount (which
sets the rate at which cryoprotective glycerol is introduced) was going
through the bur hole. We almost certainly did not transect a blood
vessel on the brain or in the dura. It is possible that this behavior
just may be normal for uninjured brains.
Dennis perfused beautifully to a 4.5 molar glycerol concentration with no
brain swelling; in fact, the bur hole and x-rays indicated a little
shrinkage. Such a good perfusion was the result of a number of factors;
Cynthia's complete cooperation, Dennis' personal physician who wrote
pre-mortem prescriptions to limit ischemia damage, an incredibly
cooperative nurse, relatives who started out semi-hostile and became
supporters, a number of friends, a team which could recover from glitches
minor and major, and a large amount of luck.
After a suspension I always take time to reflect on how things went, and
how we might improve them. This one, coming just before Mike Darwin's
resignation became effective, has more the flavor of "can we ever do this
well again"? I think we can, but it is very clear to me that a lot of
hard work (and money!) will be required to even partly replace the skills
and leadership we have lost.
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