A torn Vena Cava

Graphics by Sheldon Kahiga

An abdominal scan showed that Syombua* had free fluid in her abdomen. She had been involved in a grizzly road accident that claimed the lives of two others. Syombua made it here just in time to create drama that had never been witnessed before in the many years of existence of our hospital. When you have been around in medicine for some time, you kind of know the kind of patients you need to treat with utmost urgency and those that you can buy some time. It is a survival trick that has kept me afloat as a medical intern. Syombua was to be treated as an emergency.

I informed the surgery resident of the ‘bad case’ we were about to have and went straight to the theatre. With emergency operations such as the one Syombua was scheduled for, you don’t want to be the one delaying the operation. Again as a junior doctor, if you lack some semblance of urgency in you, people might be tempted to think that you are not a good doctor.

“Skin incision time, 5pm, ” I said as I reached out to the diathermy on a tray across the patient. Getting into the abdomen was becoming a favorite habit of mine. The abdomen that whets my surgical appetite remains that of a 21-year-old petite lady with an ectopic pregnancy. If you are meticulous, you can operate on such an abdomen with textbook precision, word by word, step by step.

Syombua was undergoing an explorative laparotomy, an operation that involves ‘blindly’ going into the abdomen and dealing with problems you find in there. Such an operation becomes so unpredictable because everything you do will depend on what you find. The plot only thickens when you don’t find anything or when you find a problem bigger than your capacity to solve. Often times it is the latter that will haunt you the most.

A gush of clotted blood confirmed our entry into the abdomen. I peeped a little at the vital signs on the monitor a few inches close to the head of the patient and immediately knew we had no chance at life whatsoever. Yes, we could go look around and solve the problem, but evidently,  we could not make it in time for the return journey. As the clots were falling apart, the blood pressure was also dropping ruthlessly. 32/20 mmHg was the last reading my brain recorded. That was severely low blood pressure. The monitors were beeping endlessly, sending a few chills down the spines in theatre, including the one on the table. The last place you want someone dead is on the operating table. This is the nightmare of every surgeon. It is career-changing for a junior doctor.

The surgical resident had kept the consultant on call on the loop. He had even told him to get on his way just in case we got stuck along the way. I was the primary surgeon at the start of that operation but I ended up on the assistant’s side as the drama continued to unfold.

Having sensed that things were taking a turn for the worse, the resident instructed one of the nurses to call the big man and ask him how far away he was. The big man said he is on his way. That’s 45 minutes if he uses Southern bypass to get to the hospital.  Meanwhile, we needed to figure out what was happening in this abdomen.

The torrid stench of poop that emanated from the damaged intestines didn’t seem to bother us. The liver featured prominently on the right side of the abdomen. Of all the livers I had seen and touched, this one was unusually pale and mottled. It had no injuries, nonetheless. The spleen was equally intact. These two organs are notorious for bleeding in accident victims.  The intestines had multiple injuries, so severe but not severe enough to create that dam of blood that was staring coldly at us. “Doc, hebu tuangalie the retroperitoneum,” the resident said in our quest to find the bleeding culprit. As I pulled the intestines gently out of our way, some thick watery fecal matter jetted out from one of the loops, staining my mask before some settled into the abdomen to add to the mess. “F*ck! Get me another mask please!” I said with urgency, hurting under the smell of poop. The student on the call with us was gracious enough to be of help to me. I heaved with a sigh of relief and thanked the student countless times as I refocused on the operation.

The retroperitoneum is the space between the intestines and the back. It has large vessels in the body. An injury to this region can be very unforgiving. Bleeds are torrential, intestines are stubborn and visibility is oftentimes limited. This is the valley of the shadow of death, a playground only for the most experienced in the trade.

Syombua’s vena cava was torn, almost dividing into two.  It bled slowly but steadily, life ebbing away along with it, like a satisfied child slowly drifts to sleep at the sound of a lullaby. You should have seen the despair written on our faces when we saw this. Every time we tried to control the bleeding, it almost always came back to us with more zeal and rage, like the Victoria Falls on River Zambezi. The die was cast. Everybody around was not convinced that we could lose someone after trying that much.

The consultant arrived in theatre not so long after the phone call. He didn’t have his personal scrubs and so he looked funny in those single-use hospital scrubs.  “Daktari, wachana na matumbo kuja ufanye compressions!” He shouted looking to my side. I knew we had no chance at all, no matter what. I begrudgingly climbed onto the stool on the side of the bed and started the compressions. I positioned myself comfortably because I didn’t how long I would be standing there, clutching at the straws.

“Get me some intracardiac adrenaline!” The big man gave instructions. He meant that the adrenaline was to be injected directly into the heart to try to jumpstart it. I had never heard of such a move before. “Sir, we no longer give that according to current literature,” the anesthetist replied with some sternness we had never witnessed before in theatre. “Leta nijiwekee, ” the big man retorted, grabbing a syringe of adrenaline into his hands. He pushed me aside a little and then fixed a long needle onto the syringe and injected the heart. A pulseless electrical activity appeared a little on the ECG tracing and the whole line became straight. The tension between the surgeon and the anesthetist was piling and every time the surgeon talked, he avoided the eyes of the anesthetist. Basically, it had got to the point of kuvumiliana.

I was getting tired of the compressions. I asked one of the nurses to help me so that I could gather some more energy for this exercise in futility. Syombua continued to lie calmly on the table, unperturbed by our ambitions. Her pupils were fixed and dilated. The coldness of the theatre, as well as that of death, had slowly crept into her body. The consultant surgeon stood still behind our backs, still in disbelief that the worst had unfolded right before his eyes.

8pm. With fallen shoulders, we closed Syombua’s abdomen with the same dexterity we would have accorded her in life. And just like that, she crossed over to the other side. The theatre retreated back to silence. The hooting of matatu across the road was now becoming louder. The life around was moving as it would on an ordinary day.

“Patient arrested in theatre. Cause of death – Multiple organ failure due to massive blood loss,” my operation notes read.

* not her real name


Author: Dr. Kiaye Oliver

I am a dreamer. I love medicine. She is generous. I am also in love with literature, she makes me see the world the way I want to and sometimes the way it is.

15 thoughts on “A torn Vena Cava”

  1. That was an intense one. A person’s death in a matter of seconds, numbers and life _altering decisions. For a whole minute I thought I was smack in the middle of a Grey’s anatomy surgery room. This was a great read

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