Well written, sir.Primum non nocere…first do no harm… is a mantra that has been around for a very long time (?Hippocrate).
My colleague was mentioning repair of an aortic aneurysm or ruptured AAA. This is a condition more common in men that have smoked and above the age of 65. But anyone with atherosclerotic disease can get it.
It starts as a dilation of the aortic artery. If found and small it may just be monitored. If large then discussion with patient on management (Stent vs open surgery).
The concern is spontaneous rupture. If rapid, this causes a very rapid death. If slow it may present as abdominal or back or testicular pains. It can be a little tricky to diagnose initially, so high index of suspicion is required. The feeder vessel to the spinal cord can vary quite significantly from person to person. It may already be tenuous because of the atherosclerotic disease the patient will invariably have, it might be right in the way of where you need to clamp it to stop the patient bleeding out in front of you, it may be difficult to see or get access to because the belly is full of blood and dying gut. Or the dynamics of flow may mean that although patent the flow of blood to the cord may be impaired During the cross clamp of the aorta.
How we approach the management of these patients depends on many factors. The end result is to have a patient alive and obviously in reasonable condition.
But if the patient is already in crap condition before you start, then it may be more appropriate to allow the patient to be comfortable with a morphine infusion, and die that way. This is big surgery in the emergency situation with higher mortality rates. In those in poor condition. The use of endovascular approaches to stent the inside of the vessel with bespoke stents has revolutionised treatment of this condition. With patientS previously cons inoperable able to be treated. But they may still have aberrant feeder vessels. They may still have poor renal function from diabetes or whatever that complicates the process. Their lungs may be crap their heart may be crap they may have poor cerebral vascularity. Each patient will have their own issues.
Ruptured thoracic aneurysm are an extra level of crap as it may dissect up to the heart, you may need a valve replacement at the same time. It’s long laborious surgery requiring heart lung machine.
we are all too well aware of Primum Non Nocere.
A case that has lived with me, in a manner not unlike PTSD, was a ruptured abdominal aortic aneurysm in an ex-marine with loving family who had been twice denied an elective repair due to anticipated problems, surgical and non-surgical, by different vascular surgeons.
As Capt K points out, he had many co-morbidities, and was best described by C Dickens in The Pickwick Papers. He was morbidly obese, smoked, had sleep apnea, diabetes and grew so short of breath when lying down flat that he always used three pillows for sleeping. He'd been in heart failure just days before his emergency admission with intense abdominal pain.
I met him after the ER treated his dropping BP with five bags of fluid and an hour in the CT scanner during which he was unable to lie still, and so they sedated him with the result that they got the pictures, but he needed intubation soon after.
Suffice to say, nine hours and five graft attempts later (the aorta just kept shredding with suture tension), the belly was full of blood & the labs I was getting told the story. This guy wasn't going to make it and the preop evals rejecting him as a surgical candidate were spot on.
I hand ventilated him in PACU with family at bedside in the dark hours of the day until they told me I could stop. Went to his funeral and didn't feel ok for weeks. Still recall that day with aversion.
Many of my finest interventions with patients has been to encourage families to consider alternative endings for their loved ones' life. Malnourished patients with yards of dead bowel, octogenarian patients with fatal cancers and septic shock, patients with devastating neurological outcomes all deserve a rational decision be made, and not a reflexive "do everything."