internal bleeding and high tech non-surgery

Monday, December 14, 2015

A year ago, Alex Smith of the Kansas City Chiefs fractured his spleen. A month ago, Indianapolis Colts’ quarterback, Andrew Luck, broke his kidney. Last week, San Jose Shark Logan Couture, tore an artery in his thigh.  A generation ago, all three would have undergone major surgery, but technology advances quickly in medicine and has made these disastrous injuries, potentially less disastrous.

ct abdomen

It comes down to being able to look inside the body without having to make an incision. The clinical decision to operate was once  made by a surgeon at the bedside, based upon history, physical exam and the stability of the patient. Exploratory surgery in the stable patient has been replaced with CT scans and angiograms. The ability to stop internal bleeding has become part of the skillset of the interventional radiologist. In trauma situations, the surgeon and radiologist are able to sometimes decrease the need for emergency operations and save some organs, like the spleen and kidney, that only a few years ago had to be removed.

Surgeons like to operate and no doubt that is why they tolerate years of training, to be able to hone skills that lets them cut into the body. In trauma, though, many patients are relatively stable when they present to the emergency department. That means they are awake and have normal vital signs including blood pressure and pulse rate. This gives time to figure out whether what injuries are present and whether a trip to the operating room is needed. All bets are off when the patient is hypotensive (low blood pressure) and seems to be bleeding to death. In this situation, going to the OR emergently seems most prudent, reasonable and the lifesaving thing to do. But if the patient is stable, technology can help look inside the body and sort things out.

In the trauma situation, a FAST scan (Focused Assessment with Sonography in Trauma) can use ultrasound at the bedside to look for blood in the abdomen, chest and surrounding the heart. If the ultrasound shows blood and the patient is unstable, it’s off to surgery as soon as possible. If, however, the patient is stable, a CT scan may be used to look inside the abdomen for injuries to the solid organs like the liver, spleen or kidney. Once upon a time, damage to those organs meant an automatic trip to the OR, but research and experience has shown that the body can heal itself relatively well and damaged organ parts may not need to be removed. With a dye injection that is part of the trauma CT, bleeding arteries can also be identified and instead of rushing to the operating room to tie off a bleeding artery, an interventional radiologist may become the hero of the moment. Threading a catheter though the femoral artery in the groin, the specific bleeding blood vessel can be identified and clotted off, sometimes preventing major surgery.

Spleen injuries are not uncommon, especially if the lower left ribs that protect the organ are damaged. Often the bleeding is contained within the spleen and nothing more needs to be done, other than watch it heal. This is the Alex Smith situation. The diagnosis led to close observation and a few months of healing. The spleen is an important organ that helps filter damaged cells from the blood stream and also plays an important role in the body’s immune system. It is much preferable to have a spleen than not.

For Andrew Luck, he was unlucky enough to fracture his kidney. The kidneys sit in the right and left flank and are protected by the lower ribs and thick back muscles. Still, a blow to the area can damage the kidney by breaking it and causing extensive bleeding. It is better to preserve a kidney instead of having it taken out, and CT can check out the anatomy, injury pattern and risk of bleeding. often, the kidney does fine if it’s left alone. But if needed to be removed, it is fortunate that the kidneys come in pairs and losing one is not necessarily a disaster.

The anatomy of the kidney and the spleen are somewhat similar in that both have segments or poles that have distinct blood supplies. If only part of the organ is damaged and continues to bleed, the radiologist can intervene and control that bleeding and still preserve the rest of the kidney or spleen by the threading technique to find and clot the offending artery.. The organ part without blood supply dies but this is a much better situation than needing to cut into the body. and hack it out. This ability to attack a single blood vessel also saved Logan Couture from having his thigh sliced open to find the bleedig artery in his thigh and tie it off. Instead, the internal bleeding was control in a very high tech way.

Technology has changed how medicine is practiced, especially with the ability to look inside the body. Future generations of physicians and surgeons will look at the care provided in the 21st century as barbaric, yet it’s what we have and it’s better than what we had. The only people who might bemoan the advances are surgeons who marshal their enthusiasm to operate with the understanding that it’s important to pick their patients wisely. In the right situation, the mantra of  “a chance to cut is a chance to cure” has been replaced with “good things come to those who wait”  and “patience is a virtue”.

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