The Leaking Aneurysm

The worst of partialities is to withold oneself,
the worst of ignorance is not to act,
the worst lie is to steal away.

- CHARLES PEGUY
(1873-1914)

A few months ago, I was faced with an exceptionally difficult situation. It was fairly routine to start with. A 68 year old man was brought into A&E with a leaking abdominal aneurysm. He was in hypovolemic shock and I was the surgical doctor on call. It was obvious that he needed urgent surgery and I spoke to the vascular surgeon on call and agreed to transfer the patient to the oeprating theatre while he got to the hospital.

The patient was on the operating table, fully anaesthetised, 30 mins after I first saw him in A&E. And, he was deteriorating fast. The consultant anesthetist asked me if I had clamped the aorta before. I said that I had never done it before though I had assisted numerous aneurysm surgeries and knew how to do it. I said I probably could do it if the situation was desperate. At this stage, I asked the theatre staff to try calling the vascular surgeon again. But, he had already left his home.
I seemed to have little choice left. I opened him up. He had a very large retroperitoneal leak. I dissected to the top of the aneurysm, found what felt like the neck, dissected down to the vertebrae and applied a clamp. However, it was not effective as I would have expected to be. I struggled for a few minutes and then decided to leave the clamp on and just press hard on the aorta!!! ( I don't think that is a particularly effective maneouvre.) The vascular surgeon came approximately fifteen minutes after I had opened the patient. The patient now had a sytolic pressure of 80mm with full inotropic support. He spent 5 mins exploring the neck and it became clear that the quality of the suprarenal aorta was so poor that it would be impossible to fix a graft to it. And, so we decided not to do anything further and the patient died on the operating table.

I had no doubt in my mind that I had taken the right decision to open him up, even though I had never done this on my own before. However, six months on, some of my colleagues insist that what I had done was too risky for my career and they would attempt no such thing (not even an emergency tracheostomy on a choking person in a pub). I have had a long chat with my boss and am none the wiser now. I am not sure what the law says about all this. But, if there was the slightest chance that my intervention would save the life of a patient who would otherwise die, then I will do what is necessary. And, if I am sued for causing 'death by misadventure' then so be it.