This little AAA (>4.5cm is considered aneurismal) is a ticking bomb. One day you're fine, the next you're dead. To have an incidental AAA finding, you have to count your lucky stars..you must've done something right in your past life. Its actually easy enough to treat a uncomplicated infrarenal AAA - open surgery or EVAR.
Before my day ended today, the SHO told me that there was a ruptured AAA that was coming in from a different hospital. A ruptured AAA is haemodynamically stable because the human's body is able to make fluids shift here and there. Plus the whole abdomen and the aorta's intima becomes this cling-film tamponade. So if you try to give in too much fluids or try to increase the blood pressure it disturbs that sensitive equilibrium and all hell breaks loose.
So back to the story, the ruptured AAA arrived to the A&E, the patient was awake and able to talk. Lines were all set and CT was done at the previous hospital. The patient knows what danger he is in and was very well informed. He knows that if he doesn't do the surgery, he will die. If the does the surgery, there is a chance that he will die on the table.
When the Team viewed the CT Scans, turned out that he has a suprarenal AAA above his previous repaired AAA. On further slides, it showed that the Aneurysm is actually not just in the abdominal Aorta but is all the way on to the thoracic aorta as well. So a Cardiothoracic team was called for a consult.
In the end, both teams decided that he was in-operable. If it was a ruptured AAA, they can clamp the aorta as soon as they get in - which can be quick in the abdomen but it takes awhile to get to the thoracic aorta even if a sternotomy was done, by then the patient would have bled out. Just as I have mentioned before, the ruptured AAA is a very delicate object; a little change in its surroundings it will go bonkers. This happens as well when a patient is put in GA, all the muscle relaxes........and there goes the tamponade. Everything will crash. That's why sometimes they have to do the incision just as the patient is going under. There is no time to lose.
Hearing the patient talk to the Reg about his wife that is coming down and that both of his kids are flying in as soon as possible, just put a lump in my throat. At that time the decision has not yet been made about his status and we were preparing for OT. In my head, I was thinking - OMG, he is going into OT without his family by his side or even being able to see his family one more time before going in. This is a risky surgery. What happens if he doesn't make it? His wife will be just waiting, not able to hold him before he goes in.
When he was told about the team's decision to not do the surgery because to put him through all this pain would be wrong. The risk to too high. He was given the choice to stay in our hospital for further palliative care or return to the hospital he came from. All he said was "I want to go home..."
Another lump in my throat.
