It was Thursday afternoon. I spent the morning in the cath lab, and now it was time for my half day clinic session once a week where all the fellows see cardiology outpatients (those with medicaid or uninsured). Although I love the cath lab, it is definitely refreshing to be able to talk to patients, see some follow-ups, do some clinical medicine, and hang up the lead for a bit while my back pain stabilizes. Anyway, a few hours into my clinic, I hear an overhead announcement: "Anesthesia Stat to the CCU" That usually meant someone is having severe respiratory distress and needs to be urgently intubated by an Anesthesiologist. But hey it happens, especially in the CCU, so no big deal. I continue my work. A few min later I here "Code Blue, CCU" That meant a cardiac arrest. But usually the docs and staff could handle that in the CCU, they don't need the "Code Team" to come and help. That probably meant that they had some MSD's (Multiple Simulatenous Disasters) and needed some man power. I begin to get slightly curious, but eh no biggie. Then a few minutes later, I hear "Code Fusion". Ok now I'm definitely curious, and even slightly concerned. No it doesn't mean there is some nuclear reaction going on, it is short for transfusion. It means that someone is hemorrhaging and bleeding to death, and there is no time for blood typing, so come STAT with O- blood (the universal donor)! You don't hear that everyday in the CCU, and it could mean someone is bleeding out from anywhere, most likely from the groin, specifically the femoral artery--which is our common site of entry when we "perc" to obtain vascular access when performing a cardiac catheterization. I had cath'd a couple of patients that morning, and got a tad worried. Was it one of the patients I had perc'd? Did I screw something up? But the chances of that are low right? I did 2 cases that morning, and everything was clean, smooth and uneventful... So I thought... I finished what I was doing and called to inquire.
Earlier that day, I cath'd a patient with one of the private attendings. Some 80 year old lady who was super nervous about the procedure. She had a mild heart attack, and the angiogram revealed a very stenotic, 90% blockage of her Left Anterior Descending artery right where anther artery branch arises. We call it a "bifurcation lesion". Usually more challenging and tricky and higher risk. The lady was so uncomfortable and nervous she wouldn't stop moving. So we decided to stop for now, and defer the angioplasty of the blockage until a later day. When we do a catheterization, the way we get to the heart arteries is by accessing the common femoral artery (which is right below the crease of the groin). We palpate the pulse, insert a needle, and pass a wire through that needle, and then introduce a sheath over the wire, which gives us "access" to the artery. From there we put our catheters up the aorta and into the coronary arteries. Obviously one has to be careful. Going into the femoral artery means ur puncturing a hole 2 to 3mm in diameter into the artery, which is enough to make someone bleed to death! When you are done with the procedure, the hole has to be either "closed" by one of many devices, or pulled and compressed manually by brute force for about 15 minutes until the blood vessel can form a clot at the site of entry. One of the complications that can occur from this procedure is obviously bleeding. Occasionally this bleeding can be very severe. If the "stick" is too high, they can bleed into the retroperitoneum, or the space in the back of the lower abdomem. Or if the stick is lower, they can bleed right into the thigh. The bleeding can be even worse if they get anti-coagulation--which are blood thinning medications we use when we are performing an angioplasty or stent, in order to prevent the blood from forming clots on the equipment. Lucky for us we didn't "fix" anything in this lady, because if we gave her blood thinners--She would be dead.
She had her sheath removed, and was rolled back into the CCU. Things looked ok. The nurses check the groin site frequently for the first hour or two. Although sometime all it takes is a few minutes. In this case, she looked fine when she arrived, however when the nurse returned 15 min later, she didn't look to hot. The patient was still so sedated from the procedure, she didnt' even have the state of mind to call for help. By the time the nurse arrived for a check, there was a giant hematoma the size of a half volleyball in her thigh. She was bleeding--a lot and fast. You can probably dump something like 1 liter of blood in the thigh of a big person before you notice it, so she must have had like a good 2 to 3 liters by then. She was unresposnive, her blood pressure was about 70, and her heart rate was in the 130's. Immediately my awesome co-fellow who was in the unit, and another one of our co-fellows, the girl on consult, dug their fists into her groin trying to stop the bleeding. She secreamed in pain, but we had no choice. Could not give pain meds because of the blood pressure. Anesthesia was called and intubated her, the code fusion was called to pump her full of blood, and she was put on medications to support her blood pressure, because she was in severe hemorrhagic shock. Fuck. What the hell happened? The stick was "clean" I am sure of it! (Meaning I got it one shot, and there should not be multiple holes in the artery). Did she move around too much afterwards and it popped open? Did they not hold it properly? I started to sweat and get real nervous. This is the first time I have had a serious complication from one of my cases. (Minor ones yes, but this is considered life threatening!) ... They subsequently called the vascular surgeons, and given the amoutn of bleeding and her instability, they rushed her to the operating room...
In the O.R., the vascular surgeon sliced open her thigh and visualized the artery. The femoral artery (which again is where we stick to get the access) had an arteriotomy site (hole in the vessel) that looked healed and closed. There were no other holes in the artery, so the stick was clean. However, there was a branch coming off the femoral artery that was completely transected. Cut through and through. And blood was just pouring out of it! Somehow, probably a combination of the anatomy of her blood vessels, and the angle of my needle insertion, I managed to sever a branch of an artery. The sheath that was in the artery during the cases probably sealed off that branch, and when it came out, it just opened up and started pumping out blood! Thought it looked like we had gotten her to the OR in time, and she was stable.
Even the seemingly simple and routine part of a procedure can be very humbling. This is not the first time--and definitely not the last--that a severe bleeding complication can occur from a cardiac cath, even if there is no stent placed and no anti-coagulation given. The rate of a serious bleed such as this is probably under 0.5%. But that means after every 200 procedures, you statistically may be due for a bad bleed. Granted there are worse things that can happen. I've seen them all: stroke, heart attack, caridiac arrest, allergic reactions, dissecting a blood vessel, cardiac tamponade requiring emergent surgery, and plenty of others, including death. High risk. High reward. Sometimes it doesnt matter how good you are,how much you know, and how much experience you have. Complications happen. But you cannot approach things differently than you know or were trained. You must accept this rate of complications. People will want to sue you0-- no matter what consent was signed and what complications reviewed. It is something that doctors deal with. I just hope that the way things are going in the world of medicine, people don't change the way they practice, or veer off the "right way" of doing things, simply out of fear of liability. Complications. Simply another reality of medicine. Another sobering aspect that comes with that great responsibility of putting yourself out there and putting yourself--and sometimes the patient--at risk, in order to try and save lives.
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