The answer to the story of the little six year old girl...

It wasn’t until I put all of the details of the accident together along with the mental picture of the little girl lurching forward that I realized I had a surgical emergency on my hands.

The little girl was bleeding to death right before my eyes.

I opened the IV full blast, told the nurse to call the lab, “Tell them to make the draw stat and call the results to the OR… and tell em to type and cross for 5 units of packed cells (packed red blood cells).” I unlocked the gurney and rolled it out of the ER bay toward the elevators.

“What’s going on? What’s wrong?” “Your daughter is bleeding internally. She’s lost a lot of blood. We need to get her upstairs and stop it. Call your husband or whoever needs to come in and tell them to come in now.”

I took her blood pressure again in the elevator. It was 79/40. Her pulse was 115. When we got to the OR doors, the nurses were there waiting and took her back.

That accident was no “fender bender” . The girl’s mom said she was going 35 and the the guy who ran into her was “driving like he was trying to get away from someone”, which meant he was turning at 35 miles an hour at least off of the side road. He hit them in front at an angle of 45 - 67 degrees most likely , so the velocity vector straight into their car was at a minimum of 25 mph (35/sq. root of 2) to a maximum of 35 x (sq. root of 3 over 2 = 30 mph. So their car stopped dead in its tracks. Having a physics background helped me understand the power of inertia over a small child’s delicate anatomy. Stopping suddenly from 35 mph with the help of only a seatbelt made the only pathophysiology that could explain everything come into focus.

The strange mark on her chest was from the seatbelt. When the cars collided, her thorax stopped but her abdominal contents kept going for a few inches before they stopped. I didn’t know which one it was at first or even whether it was an artery or a vein but some vessel in her abdomen got avulsed or torn inside her abdomen from the stretch that occurred between the abdominal contents that are mobile (such as the intestines) and the abdominal contents that are fixed to the thorax and tethered to the peritoneum(such as the aorta).

And that’s exactly what we found at surgery. When we opened the abdomen, the whole thing was filled with blood. It poured over the sides of our incision. Within seconds of scooping the blood out and suctioning the peritoneal cavity, we found the source. The superior mesenteric artery (which supplies the small intestines and part of the colon) got jerked right off of its origin from the aorta when the intestines went further in the stopping action than the relatively fixed aorta. The SMA is a small artery and the attending surgeon on call, who was by now in the room, had to put on his loops and sew it back on circumferentially, no mean feat.

In the mean time, this little girl needed blood. Her hemoglobin came back at 5.7 mg/dl, about half of what it should be as the nurses rolled her into the operating room. This little girl had lost half of her blood volume into her abdomen in the roughly two hours since the accident. She needed a transfusion. There was one serious problem. Her family were Jehovah’s Witnesses.

People who follow this religion not only do not believe in using another person’s blood to sustain life., they don’t allow transfusions with their own blood. I knew this before that night because I had a friend from Jacksonville, Florida, where I grew up, whose family were strict Jehovah’s Witnesses.

Her mother refused to let me order blood for the little girl. “She’s going to die within the next hour- maybe sooner- if you don’t let me start the blood and I’m not talking 30 minutes from now when you finally change your mind. I’m talking now.”

She called her husband.but got no answer. He was on his way (this is in the time before cell phones). “We don’t believe..” “I understand all that. But you’ve got to agree to this or she’s going to die.” “No, I can’t sign that. It goes against our religion”. “I’m under the gun here, so I’m going to say this one more time. We’re going to find the problem and stop the bleeding. I understand how important your religious beliefs are. Her hemoglobin was 5.7 when we drew the blood downstairs. That was about 20 minutes ago. It’s probably 4 point something now. It’s supposed to be 11. In a little bit, she’s going to have lost 2/3’s of all the blood she had in her body and that’s about all a person can lose in a short time and survive. If you don’t agree and sign that consent, I’m going to ask a judge to sign parental custody over to myself or the attending doctor who’s on his way in now.” She bent her head down toward the ground to hide her tears, and nodded, “no”.

I went to the nurse’s station and asked them to get a sympathetic judge on the phone so we could transfuse the girl. “ The lab is getting the blood ready. Have them bring it up and we’ll hang it in the OR when we get word from the judge.” Then I went to change into scrubs.

When I got into the OR after washing my hands, Anesthesia was intubating her and the scrub nurse was ready with the instruments laid out . After she fitted me with my sterile gown and helped me get my gloves on, the circulator finished up the betadyne “scrub” and handed me the “paint” which I slopped on the patient. The scrub nurse and I draped the patient. At this time, the attending surgen poked his head into the room and said, “I’ll be right in.”

While waiting for the attending to come in, I noticed for the first time, that the girl’s belly was bloated a little and wondered how I could have missed it before. I think it was because of the tendency of bellies to flatten out when patients lay flat on their backs. For what it’s worth, her mom didn’t notice it either.

I just knew that thing was full of blood and her pressure would drop the second we opened the abdominal cavity. I looked over the drapes at the anesthesiologist who was a young Chinese guy in his mid-thirties whom I knew well. “Chris, her pressure’s gonna crash when we open the abdomen.” “I’m on it.” “Thanks .”

The attending came in and the nurse handed him the scalpel. He handed it to me and said, “From here to here” as placed index fingers at just below the xiphoid process and just above the pubic symphosis. “Easy. She’s as skinny as Ally McBeal”, warning me to use a light touch and not go so deeply that I would cut through the linea alba at the same time and go into the peritoneal cavity where I could cut the bowels. She had an eighth of an inch of sub Q fat as a buffer and I managed to divide the skin without injuring anything beneath. And there it was, the beautiful white line of fascia between the bilaterally-symmetric bellies of the rectus abdominus muscle.

“Just ease your way in.”

I did as I was told. One short cut. Then another. Then another . Then squirt, gush. I instinctly put my finger over the hole . He took the scalpel from me and in a flash, he extended the opening and we were in. There was blood pouring over the sides of the incision as he put in the spreader and cranked it open. The nurse handed me the cell-saver (a suction device used to preserve the patient’s own blood which can be used for auto-transfusion. I dropped it into the corner of the abdominal cavity and let it suck away as we scooped out handfulls of semiclotted jello between loops of bowel and the recesses on either side. We dropped as much as we could into sterile bowls to be emptied later by the cell-saver.

As soon as we got most of the old blood out, it was easy to see some bright red blood coming from the location of the aorta. We packed off the intestines with lap sponges. He replaced his index finger which was blocking the hole in the aorta with mine and set about finding the SMA in the mesentery of the small intestine.

Right then, the front desk nurse poked her head into the room and said the judge was on the line.

“Patch him in”.

I’ll tell you it was really something to hear a judge tell us over the loud speaker, “Is this Dr. Sheftall?” “Yes, Judge, it is.” “I’m granting you the something something (I can’t remember the technical name). You’re free to provide any necessary treatment including blood transfusion, you deem necessary. This does not absolve you from liability due to negligence were it to occur.” I understand, Judge. Thank you and apologies for disturbing you at this hour.” “Click.”

And that was it. We hung blood immediately starting with her own blood from the cell saver which amounted to almost two units and then from the blood bank. Her first draw in the recovery room was over 7.7 mg/dl . She was already out of the woods.

As I walked out of the ICU later that morning after getting her situated, The parents were waiting for me.

“I’m sorry, Sir, for violating the religious tenets you’ve chosen for your family but I had no choice. He shook my hand vigorously with both of his hands and with a trembling voice, said, “Thank you.”

I think this worked for all involved because it took the decision out of their hands. We were all three in an untenable position. They were strongly religious and couldn’t bring themselves to violate their faith as Jehovah’s Witnesses, but they didn’t want to lose their daughter either, obviously. As for me, there’s no way I was going to let the little girl bleed to death with or without a consent. I’m so greatful for that judge because he took me off the hook. I most certainly would have been called on the carpet and probably would have been expelled from surgery residency for performing a procedure on a minor even as relatively benign as a blood transfusion after the parents had forbade me to do so.

Explanation of why all the signs and symptoms made sense:

The extreme thirst, inability to pee, drop in blood pressure and increase in pulse were all due to the loss in blood volume. Kidneys will preserve water to keep the blood pressure up when the blood volume gets low. This is why urine becomes more yellow (less clear) when we get dehydrated.

The painless abdomen was because the only injury was the avulsed artery which would cause negligible pain. If more time had gone by to the point where her intestines started to become ischemic proceeding to gangrenous, the pain would have been excrutiating.

The bruise on her chest being from a large flat seatbelt was painless because its the pressure relative to the force that causes pain. That’s why it hurts more to poke someone with a screwdriver than bump them with your fist at the same force. P=F/A The smaller the area for a giver force, the larger the pressure.

The muted bowel sounds were because of the blood surrounding the intestines.

How this girl’s life could have easily slipped away. She was going to be discharged to home with no complaints of pain anywhere on her body. She would have had her fill of water, starting in the ER lobby and continuing in the car and at home. This would have kicked her blood pressure up enough to keep her from fainting. She probably would have died at home after being put to bed.

There was really no reason to order labs except that I started to get this feeling that something wasn’t right, probably when I saw the big, painless bruise on her chest and she and her mother didn’t know where it came from. I know they had already been told they were going home and were anxious to leave as it was getting very late. In a way, I was stalling by ordering the labs. But when she couldn’t give me a urine sample, I knew there was something very serious going on. Except in cases like this, you can always produce some urine.

We’ve all been in minor accidents before (although this one wasn’t minor as I showed) and felt shaken but completely normal afterward. Imagine being in an accident and feeling perfectly normal, going home, and dying three hours later. It almost happened.

She’s 35 years old now.