Edgar was a seven year old boy with a hefty dose of ADHD and entirely too much free time on his hands over the summer.  One day in an effort to keep himself entertained Edgar decided to joy ride on the back of an ambulance. The driver didn’t know he was back there when he backed up, crushing him into a wall.  He felt something odd so he pulled forward and backed up again, crushing him for a second time.

Edgar arrived to our trauma center in critical condition and was too unstable for a CT scan. The surgical team knew he was bleeding but wasn’t sure where from.  They quickly inserted a small catheter into his abdomen and a large volume of fresh blood came out, clarifying the diagnosis. Edgar was hemorrhaging into his abdomen.  The surgeons rushed Edgar to the operating room, opened up his belly and found his liver split in half, bleeding profusely.

In cases like Edgars’ the best initial treatment is to remove as much blood as possible, stop whatever major bleeding sources can be easily stopped, and pack the abdomen with surgical gauze.  This is done in an effort to let the body recover quickly before the physiological effects of hemorrhage become insurmountable.  The patient is then brought to the intensive care unit, kept warm, resuscitated and, if stable, returned to the operating room in 24-48 hours for a more definitive treatment of his or her injuries.

Edgar spent 36 hours in the intensive care unit, mechanically ventilated and received several units of blood and clotting factors.  He was kept warm by a plastic blanket that is continuously filled with circulating hot air.  He was now ready for another operation, my first as chief resident on the trauma service.  One by one, we removed the large gauze pads that were placed in his abdomen at the last operation.  There was almost no bleeding but the pads were yellow indicating a bile leak from his liver injury.  The rest of his abdomen was clean.  We found a massive liver laceration practically splitting it into 2 pieces.  Liver injuries will often heal on their own, so we placed several large plastic drains in the area of the injury to drain the bile and closed.  I think we were all relieved that Edgar’s belly didn’t contain any surprises and we were all very optimistic about his prognosis. I hoped that this would be Edgar’s last operation and I am pretty sure the outgoing chief was thankful that he was no longer responsible for his care.

About 3 days after the operation, the drains in Edgar’s abdomen started filling with bile.  This wasn’t unexpected, considering the size of Edgar’s liver injury.  The problem was each day the volume continued to increase.  In fact, the drainage was so high it was hard to imagine any bile was making its way into his digestive system. The treatment for most traumatic bile leaks is to watch and wait.  They will often heal on their own over time and without any surgical intervention.

Edgar was raised by his single grandmother. A wonderful woman who was patient, caring and very dedicated to him.  She was from humble means and lived quite far from the hospital but not a day passed that she didn’t manage to visit him.  I am not sure she completely understood Edgar’s problem, but she knew Edgar had been seriously injured and that he would need more treatment. She was always very positive and upbeat and always thanked us for our work. We explained that for the time being we felt the best course of treatment was to wait a bit more.

A month after his second operation, the volume of the bile drainage had not decreased. We brought Edgar back to the operating room to try to fix the leak.  It took almost four hours to figure out that Edgar’s liver had been completely separated from his bile duct.  There was no connection at all between his liver and his intestines.  All the bile his liver made came straight out through the drains.  In addition, the main artery that supplies blood to the liver had been damaged.  We reconnected his liver to his intestines using a loop of small bowel.  We placed two new drains near the liver and then we repaired the artery.  The arterial repair proved to be the hardest part and had to be re-done several times.  After 18 hours of surgery, Edgar was wheeled to the recovery room.  I was sure the arterial repair wouldn’t work and I knew that surgically reconstructed bile ducts are prone to long term complications.  I was exhausted and not terribly hopeful.  What else did this poor kid and his family need?  He was obviously of very modest means, being raised by a single grandmother who seemed to have more than her fair share of difficulties in life.   I called her at five in the morning after the operation and tried to explain what we had done.

“I’m very sorry Ma’am.  The operation was much harder than we thought it would be. Edgar will be in the ICU for a few days, most likely the better part of a week.  The next 24-48 hours are the critical ones.  I am not sure how he will do.  He is not out of the woods yet.”  I assured her we would continue to do everything we could.

“Don’t worry doctor, after man works to exhaustion God takes over.  Thank you for all you have done.  Now it’s out of your hands.”

I would have liked to talk to her more.  I wanted to know how she could have so much faith.  I wanted to know how she could be so calm despite all she had been through and all she was, most likely, to go through with Edgar.  Where did this faith come from?  How did she stay this optimistic despite being dealt this life?  She never complained.  I wanted to talk more but I couldn’t.

When we were closing Edgar’s incision, they wheeled another trauma patient into the operating room.  A young man had been shot in the leg and had a major injury to his femoral artery with no pulse and no blood flow to his lower leg.  He needed the artery repaired quickly or he would lose it.  I phoned the vascular surgeon on call, had a quick drink of soda and returned to operating room for another four hour procedure.

Edgar spent the next 2 weeks in the intensive care unit. His liver function was pretty bad at first but seemed to recover on it’s own.  Apparently the arterial repair worked.  Eventually his bowels started working and the drains stopped filling with bile.  In short order his appetite returned to normal.  A month later, Edgar walked out of the hospital.  If you saw him with his clothes on you’d have no idea how many scars were on his little body or that he’d ever been involved in an accident at all.

Edgars’ case is not dissimilar to many I have seen.   I think that is a big part of why I became a pediatric surgeon.  Children are very forgiving, both emotionally and physiologically and have the ability to heal and bounce back from unbelievably serious injuries.

It also lets me meet people like Edgars grandmother.

About the Author
Marc Arkovitz is a pediatric surgeon practicing in Westchester, New York and an associate professor of surgery and pediatrics with more than 20 years experience working in both Israel and the US.
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