AREA CODE 805
the surgical “0” conversion to “S”
Four decades ago, I had just come to town, a newly minted surgeon fresh out of residency. One of my first cases was a call from the Emergency Room. An 18-year-old male had been stabbed in the abdomen with a screwdriver. On my way to the hospital, I thought, “This will be nothing. What harm can a screwdriver do?” I changed my mind as soon as I saw the young man lying on the ER gurney, with no blood pressure and a heart rate of 140 bpm. We went to the operating room right away. On opening his abdomen, it was full of blood, most of his blood volume, close to four quarts. The trajectory of the screwdriver was not straight, as when the boy was stabbed, he had hunched over, and the screwdriver went oblique. It hit several intestinal loops and went to the back where the main artery of the body, the aorta, was nestled against the spine. I found the bleeding point quickly as by now the pressure was weak and just oozed out of the front wall of the aorta. As I had controlled the aorta from above and below with vessel clamps, I could easily sew the hole closed. By now the pressure was better, as the anesthesiologist had given him blood and saline, building up his blood volume. But as soon as I opened the clamps, blood rushed from the backside of the aorta. The screwdriver had gone through both the front and back walls of the aorta, but because of the oblique trajectory, the back hole was two inches lower. The aorta is fairly intimately attached to the spine, and to turn it to see the back wall was a real challenge. After a couple of hours though, I could see it from the back and closed that hole as well. All was controlled, we had no visible bleeding, the aorta was open down to his toes, and we had blood pressure. Time to close and get out.
This 18-year-old was a member of a local gang. He proudly displayed a tattoo on his upper abdomen with the name of the gang. It was 805, our phone area code. By necessity, my incision went through the middle of the zero of 805. I was happy he was alive as I placed the last stitches in the skin to close. We took him off the table and transferred him to the Intensive Care Unit. He was in the ICU no more than 15 minutes when there was a code called from ICU. My patient had no blood pressure and was dying. I immediately rushed him back to the OR. Had I missed another hole in the aorta? Was there something else I had overlooked? As soon as I took out the sutures holding his belly together, the blood pressure came back, and the bowels popped out like a bouquet of flowers. No bleeding, however, everything was dry as a bone.
I was puzzled, but it came to me. When I closed the abdomen the intestine that had been without blood for at least two hours had gotten very swollen, with all the saline solution the anesthesiologist had given him to sustain his pressure, much of that saltwater wound up in the walls of the intestine. When I closed the abdomen, it was difficult to stuff back all the guts because they now had increased in volume. But I figured they came from the abdominal cavity and they had to go back to that cavity. I pushed harder.
At that time in history, the Abdominal Compartment Syndrome, had been reported but still in evolution as to cause and mechanism. This condition is when the abdominal pressure exceeds the venous pressure and the largest vein in the body, the vena cava is compressed as if it had a tourniquet around it. Blood was not getting back to the heart as it was all sequestered in the legs and could not get through the pressurized abdomen. As soon as I opened the abdomen, it was like taking a tourniquet off the main vein, and the blood could return to the heart. I now closed the abdomen with a plastic sheet patch, that I fashioned by slitting an empty plastic bag of saline open. This allowed the intestines more room, and it was not compressing the vena cava. He did just fine and recovered. Since the skin had to be left open, the divided zero was like two mirror image “C’s” and when the skin was finally closed, the two halves of the 0 did not line up and healed as an “S.” His pride membership in the 805 gang was now the 8 S 5, not heroic and not to his liking.
You would think he would be grateful to me for saving his life, but … 8 “S” 5 was too much for him to tolerate. To say that he was displeased with me would be an understatement! But life goes on, and he moved out of my town. Good thing too, as I don’t think he would have survived another screwdriver.
I, on the other hand, still kick myself forty years later for not having written up this case. Although various “compartment” pressure elevations had been mentioned as long as 100 years ago, the modern understanding of the abdominal “compartment” was not fully worked out until the late 1980s and 1990s, my missed chance for a claim to glory and fame.