As general surgeons, one lesson we learn early—and repeatedly—is to expect the unexpected. We train intensely to prepare for everything and anything, yet emergencies still find a way to surprise us. They rarely happen at convenient times or during normal hours; instead, it is when we are already busy with other aspects of life. We might complain about such inconveniences, yet such disruptions are minor compared with the experiences of our sick patients, who often must deal with a serious, sometimes even a life-threatening issue that they never expected.
Halloween is always a very festive time, and never more-so than when my kids were young. In their preteen years (and beyond) they would dress up and would trick-or-treat through the neighborhood. It was an event not to be missed. One such Halloween, after some persistent and persuasive nudging from them, I decided to ‘costume-up’ myself. I accompanied them around the neighborhood in a headless-man outfit cradling my severed head in my arms. It looked frighteningly convincing—and, in a macabre way, oddly appropriate. This was during the height of Harry Potter mania, and my daughters were dressed in robes adorned with the green crests of Slytherin and scarlet ones of Gryffindor, the two famous rival houses at Hogwarts, the fictional school for young wizards and witches.
Making the rounds of the neighborhood was always a treat, especially seeing the neighborhood kids (and their parents) in their often-outlandish costumes. Then some of our close neighbors would try to lure the parents with “adult” beverages. I was on call, and so sadly could not indulge—not even one (as that’s always a guaranteed call; another one of Murphy’s laws).
Yet we had barely completed a third of our neighborhood trek when my pager erupted. After a few curses and just as much fumbling through my garb—first for the pager, then for my phone—I called the number that appeared. At first, it did not make a whole lot of sense, as I recognized the number as our radiology department. The nurse answering explained that they were concerned about someone who had come in late for a scheduled mammogram. Luckily, our conscientious radiologist had stayed late (it was a different time).
I could not understand why I was receiving an urgent call from the mammogram department and thought that they must have found something unusual on a study and decided to give me a heads-up, as tended to be their practice. But when the radiologist—someone I had worked with for years—came on the line, his usual congenial tone was gone, replaced by concern, immediately suggesting that the nature of the call was far more serious.
“Nick, I have a patient here who collapsed during her mammogram,” he began.
I wasn’t sure why he was calling me. Someone fainting in radiology would not usually entail a call to a surgeon. His next few words explained everything.
“Her blood pressure plummeted. I did a quick ultrasound of her abdomen—and it’s full of blood.”
He immediately had my full attention. My mind raced through the possibilities, but before I could respond, he had named the one I feared the most.
“I think she may have ruptured an abdominal aortic aneurysm.”
We exchanged a few more details, and I told him I would be right in. I asked him to get the emergency department team to help resuscitate her and arrange to move her to the surgical area. Still holding my severed head with one hand, I used the other to call in the surgical team.
The word aneurysm is usually enough to get any doctor’s attention. Add ruptured, and the conversation changes entirely. I knew that we had a life-and-death emergency unfolding.
An aneurysm is a bulge in an artery caused by weakening of its wall. It can develop in arteries throughout the body, but, as in real estate, location matters most. Two particularly dangerous sites are the arteries supplying the brain and the abdominal aorta.
In the brain, a “berry” aneurysm is a small, pouch-like bulge in an artery. If it ruptures, it can cause a sudden, devastating headache—often described as a thunderclap—and bleeding that may be fatal. Smoking and high blood pressure increase the risk, but apparent good health offers no guarantee. I will never forget a medical-school classmate who died from one before the age of twenty-five.
For a general surgeon, the more familiar emergency was a ruptured abdominal aortic aneurysm. The aorta is the body’s largest artery, carrying blood from the heart under considerable pressure. When its wall weakens, it can gradually balloon outward, rather like a weak spot in a tire’s inner tube. That enlargement is not necessarily steady or predictable. But a principle known as Laplace’s law helps explain the danger: at a given pressure, increasing the vessel’s radius increases the tension in its wall. As the aneurysm enlarges, the weakened wall must withstand greater forces.
Eventually, it will give way.
What happens next depends largely on where the blood goes. If it spills freely into the abdominal cavity, the patient can bleed to death within minutes, often before help arrives. Sometimes the surrounding tissues temporarily contain the bleeding. That may buy a small window of time to reach the operating room, control the hemorrhage, and repair the rupture—but it remains a catastrophe.
The word contained should never be mistaken for safe. The tissues holding back the blood are no substitute for an intact artery. A partially contained leak can become an uncontrolled blowout without warning.
Time is always our nemesis.
Many patients never reach the hospital. Even among those who arrive alive and undergo emergency repair, the risk of death remains substantial. Stopping the bleeding is only part of the battle; the body must also recover from the shock and the damage caused by inadequate blood flow to vital organs.
Treatment has changed considerably over the course of my career. In suitable patients, surgeons can now repair a ruptured aneurysm from inside the artery using an endovascular approach. A fabric-covered stent, usually introduced through arteries in the groin, creates a new channel for blood to flow through the damaged section. It seals off the aneurysm from the circulation rather than allowing blood to continue escaping through the tear.
The blood already lost into the surrounding tissues remains there, but once the bleeding is controlled and the patient stabilizes, the body can gradually reabsorb it.
This approach has expanded our options, but it depends on more than the availability of a device. Is the patient’s anatomy suitable? Does the hospital have the equipment and an experienced team ready to use it—even at two in the morning? If not, can the patient survive a transfer?
Those questions concern me, particularly in smaller hospitals. Concentrating vascular surgery in specialist centers can bring considerable expertise, but it also creates a practical problem: the patient must get there alive.
As more aneurysm repairs move to regional centers, I worry about the loss of local experience with open repair. What happens when a patient is too unstable to travel and the surgeon nearby no longer has the team, resources, or experience to operate?
That is not an argument against progress. It is a reminder that progress must include a way to deliver care in time.
For a patient with a ruptured aneurysm, the distance to definitive treatment is measured in more than miles.
It is measured in Blood.
On this particular Halloween, long before today’s endovascular techniques were available, a ruptured abdominal aortic aneurysm had to be repaired with open surgery. That meant a large incision down the abdomen. I had performed the operation many times, and my results were about fifty-fifty: of the patients who made it to surgery, roughly half made it home. Those were sobering odds, but far better than doing nothing. The operation was only one of many hurdles to be tackled. These patients were often older and had heart, lung, or kidney disease. Any surgery would have been risky for them. Emergency surgery for a ruptured aneurysm was another matter altogether.
There was no time to go home and change. I left my two daughters with a neighbor and hightailed it to the hospital, one hand still holding my severed head. By the time I arrived and changed into scrubs, the patient was in the preoperative area. The surgical team was preparing the room while the anesthesiologist began his work. Timing mattered. Once the patient was anesthetized and her abdominal muscles relaxed, the pressure that had been helping contain the bleeding would fall. A fragile rupture might then give way completely. We had to be ready to act at once.
Over the years, I had learned a technique that could buy us precious time. By passing catheters through the arteries in the groin and inflating balloons in the aorta, we could temporarily reduce the blood flow while we worked to place clamps above and below the rupture.
Even after opening the abdomen, reaching the aorta was no simple matter. It lies deep, behind the abdominal organs and just to the left of the spine. The rupture was usually below the arteries supplying the kidneys. If there was enough healthy aorta between those arteries and the rupture, we could place a clamp without cutting off blood flow to the kidneys. If there wasn’t, the operation became more dangerous still.
The first thing we encountered was blood. Lots and lots of blood. The torn artery did not sit in plain view, waiting to be clamped. But rather it lay buried beneath a mass of blood, clot and important structures. Sometimes we had to work through that clot with one hand while the other tried to hold back the bleeding, searching for a place above the rupture where I could gain control of the artery. An anatomy textbook makes the task look almost straightforward: arteries red, veins blue, every structure distinct. In a ruptured aneurysm, everything was a shade of bloody burgundy. Many times, it felt like surgery by Braille. My fingers searched for the structures I knew should be there, while my eyes offered only limited help. That sense of touch took years to develop—and some hard lessons along the way.
Finding and clamping the aorta above the rupture gave us a measure of control, but the job was far from finished. Below, the aorta divided into two iliac arteries, one leading toward each leg. We had to find and control those as well. Each had its own hazards. The left iliac artery, in particular, lay close to a large vein that could be injured during the dissection. I had learned in training just how difficult bleeding from that vein could be to control. Only after we had gained control above and below the rupture could we turn to repairing the artery itself.
Many hospitals don’t have the ability, equipment or expertise to perform these interventions and so the patients are transferred. But this transfer takes time. Precious seconds, minutes and even hours that the patient does not have and as a result many succumb before they even get an intervention. This is the most important reason why community hospitals must offer intervention and not just become a ‘post office’ to mail patients elsewhere.
Time waits for no-one.