War Surgery

A four hours surgery which made me exhausted

It was 1986 when in one of July days of that year I was called out to the emergency hospital, room care in Dezful city at fourth Air Force Base.

There was 24 years old, an Army soldier wounded by a piece of shrapnel.

Each day, I always had many wounded army soldiers during the war. At that moment, I had several thousand surgeries but the most shocking surgery is the one that I will be going to describe.

The war wounded man, laid on a stretcher in a sea of his own blood, there was a hole in his left chest dressed intensively and under pressure and the whole set of his chest paste and dressing was wet by his own blood.

At least, a chest tube was assigned for him in the front line of the battle field in a mass casualty situation but this was the fourth vial filled by blood, this means that it cannot be a delay to chest tube and chest opening was indeed necessary.

The situation was so fatal that I told them I don’t need chest x-ray or radiological photograph. I said that there is no time for these works.

The young wounded man was taken to the operation room and was laid on surgery bed with blood pressure level 5 and was anesthetized.

I went for washing my hands … surgeons usually have to wash their hands by brush antiseptic for wearing the mask, and formal surgery room dress, drying hands, wearing gloves and fastening dress by the operation theatre personnel. Anesthetization said that blood pressure was on level 5 and it was going to drop to 4.

Penetrating trauma causing central bleeding into a body cavity requires surgery of Some sort and severe internal hemorrhage may require urgent operation as part of The resuscitation process. Such patients have a high priority for surgery. I act immediately; there is no time to wash hands as Dr. said.This falling blood pressure will result in Hemorrhagic shock and

Incapacitate kidneys. Anesthetist, Dr. Jamdar. Replied that there is no time to waste.

I was wearing a suit and a beautiful white shirt.

for copy

I took off my coat and put on a pair of gloves and I incised all the skin and major and minor pectorals muscles and kept inter-rib muscles away and opened thorax which a flood of blood disordered my vision.

I fixed Rib retractor was keeping ribs away from each other, between both ribs locations and I was turning its handle to keep ribs away and find enough location for vision and function, by all these endeavors I could provide a small-sized location.

In lowest visibility, severe bleeding and meanwhile the left lung, was inflated under pressure of anesthetization machine and made an obstacle for our function and vision and was deflated.

These actions were so iterated that we heard the voice of rib breaking due to Rib retractor tension. I did not mind at all as long, he should be kept alive.

The suction pump was operated and suctioned blood within thorax with a disgusting sound to allow me to see bleeding location

I could not find bleeding location in no way losing a huge volume of blood.

The patient was getting blood from (2 blood bags) and isotonic crystalloid solution.

Yes, the left pulmonary artery was possibly torn or perforated.

I progressed to pulmonary navel with the left hand and compressed thumb and number 2 fingers … in surgery fingers have numbers I controlled the left pulmonary artery but where? 15 cm in depth of bleeding notch I found that with touching not by seeing.

How strong was this artery? How I could enter and fasten clump with this low vision and this massive internal blood.

Meanwhile, internal mammary artery along with three intercostal inter-rib arteries bleeding: My left hand was becoming too numb.

Surgical technicians took the left lung in a side but it was inflated due to artificial respiration machine if they didn’t take the lungs I had no that narrow space. .. at that moment, both of my hands were busy.

I was thinking to myself, why human being has no more than two hands?

I wish I was a bird and taking internal mammary artery with my beak.

I was wondering to myself how I got involved in this situation?

If you progress layer by layer and have enough time in surgery you can either block or clump bleeding arteries or cauterize them. But what could I do In this surgery in which thorax was opened extremely quickly and if we had no such speed we would lose the patient?

Bleeding and foraging large blood clots caused Mediastinum shift among (the most dangerous possible events in one-sided chest hemorrhages) tension pneumothorax. Chest central part where the heart and Pericardium and large blood arteries are placed there a very horrible place for surgeons in, shift was changed right- handed and if this curvature and shift would not be corrected both lower vena cava inferior and the upper vena cava superior one and having thin walls would be bent and closed and blood will return heart from head and body no more.

My left hand became numb and would loosen soon, ask surgery technician front of me to enter the right angle, (a type of surgical clump and proceed it deeply to a place of my hand fingers place only by touching not seeing apparently… it was a fruitless endeavor. Suddenly I left internal mammary artery compressed above which by my hand and targeted pulmonary navel depth via right angle and blocked a dentil touching side of my fingers.

It was well done apparently and bleeding has been arrested, and artery hemorrhage was stopped.

I want to raise my number and tired hand that I noticed ”oh my GOD the glove ridge was trapped with a clamp.”

Who can open the clamp and put it again on the right location exactly? I said.

”Okay I can bring out my hand from the glove and changing the glove” …. Cold sweating I filled at my whole body ….because, I did not wash my hands before this surgery!

In all my life experiences, during this field when I had to turn out the hands of the angel of the death and disappointed him to back off. I will face the hardest situation like this which ”I agree to the death of the patient eventually.”

The death was flying over the operating room. They wanted to take him away.

However,

”It was necessary for me to challenge this battle because the life and death of this patient were depending on me and God.”

Could I succeed?

The operation was repeated again and this time my life was like a clock doing tick tack in my heart thinking any second will ready to explode from too much stress and tiredness rather than a patient. This time taking artery was correct and complete.

In this period surgery technicians took and blocked the internal mammary artery.

I catch a comfort breath.

Although we have done all these operations smoothly thorax was full of blood again and the suction pump was evacuated it.

I asked myself which blood-vessel I took. But bleeding is continuing different way than before.

Blood clotting problems would have occurred if bleedings could no longer be blocked if the conditions continued in this manner.

In effect, good blood of patient containing plackets was losing and however, he took blood from blood bank but that blood was not as good as this fresh blood.

Hemorrhage process differed from the previous time!

How thorax had vein bleeding insidiously.

”Maybe Azygous vein is bleeding.”

I told myself I can`t see Azygous.

Maybe pulmonary vein which always is placed in the same sheet with pulmonary artery was perforated by shrapnel and damaged. Discharging blood was restarted.

I precede the thumb, disabled left hand into thorax depth.

Yes, the left pulmonary vein was perforated and torn as I thought.

Hemorrhage was stopped but now satanic intercostal arteries are still bleeding.

Using “satanic” term for these arteries because they are the lone arteries receiving blood from both sides, both from aorta located at the back of skeleton and from an internal mammary artery in front of the chest. Thereby, when they are cut they bleed from both sides.

Its necessary for readers to bear in mind that it’s not easy to find arteries in their incision place human body when they were incisional but they would be like elastic bands and each of distal and proximal ends would be released in depth of muscles and badly bleed.

Another point is that if rather large veins and arteries go into an organ they could not be blocked because that organ suffers from lack of blood but it should be repaired.

Pulmonary artery and vein should be repaired i.e. patching and sewing.

During the start of repairing one, my hands were busy and by another hand, I took the thread and needle and directed them to repair perforated veins and at the same time, two surgery technicians were controlling threads and cut knot ends and were drying operation place and did suction and so forth. All of us were extremely busy.

Anesthetist, Dr. Jamdar bravely evacuated patient endotracheal pipe and placed a pipe was directly going into the right lung.

The endotracheal pipe is the same vital pipe transferring oxygen and anesthetizing gases to the lungs.

By this action, the total responsibility of patient oxygen taking was given to right side lung.

The left lung was deflated and this provided a good vision for repairing artery & veins-

Repairing lasted 2-3 hours.

I was extremely tired; suddenly I realize my white shirt golden cuff button into the thorax.

“Oh my God” I’m doing this so important operation with a suit and a pair of gloves and I was not even paying attention.

If the chest surgery operations are not performed extremely clean pyothorax- filths within the thorax- would kill patients in less than a day.

It was a very good and successful operation and patient blood pressure was completely corrected now. I took clamps, blood was passing from its natural route and I have seen the pulse I placed chest tube pipe and well washed within the thorax, I took rib retractor and sewed walls.

Although it was a successful operation and patient blood pressure was completely corrected, I felt ashamed.

Thoracotomy and chest surgery operations are considered among huge and sensitive surgery operations … a surgeon should be completely equipped and observe cleanness, not with the suit and white shirt of last night ceremony. Of course, my entire suit was cover with blood.

This young man was going to die any second if I did not follow anesthetist’s words and now he survived.

But I could not forgive myself and felt ashamed for not wearing regular operation medical dress code uniform. When I rose my head I saw others in the room they were looking at me with smile and respect and often called me bulldozer because of skill and speed during work and taught that I had extraordinary bravery and temerity, physical power.

I said to myself human should not go into the well with other people rope.

What was terrifying in this whole story was that all operation room personnel’s saw me performed a huge surgery with black tie and if I followed the standard method of each famous surgeon of the world- doing surgery operation after washing hands and wearing operation dressing and mask- the only work remained was writing the young man deaths paper permit.

Yes, in that case, I observed operation room rules as a morgue, not for a young man place. Then, a reader should think that I was right to do a non- standard action in that extreme condition. Of course, his healing was not because of me it was controlled by his powerful GOD and maybe this was the creator who told me, Nasser …… does not require to X-ray … It’s not necessary to wash your hands Only do the operation … the rest of the procedure is given to me.

I was a servant to follow.

After finishing this successfully procedure I was having nightmares for two nights keep thinking about the patient may get Pyothorax ( deadly lung infection pulmonary puss ) …thinking my patient was suffering from pulmonary infection did not allow me to relax.

Think that I extremely endeavor and then suffered from insomnia, stress and of course anxiety.

What are the pyothorax sign and symptoms? Aha, fever, chill, dyspnea and emerging either green or yellow puss within thorax and chest tube glass that thanks to GOD he had no one of these signs.

In the second day after surgery, he said that he feels hunger I ordered a diet. He was under extremely caring in I.C.U, there was no fever, no chill, no puss.

First, I took a chest x-ray, it was magnificent really magnificent, I took chest tube pipe out.

Sutures (stitches) were removed after some days as well.

It was over. At that time, I was an air force major, and I had college friends who were captains and air force pilots … I regarded this event, as a fighter plane Capitan with only an ordinary clothes command a pilot to battle with enemies and he is told that there are no times just fly, target into the battlefield and attack.

It’s the Almighty God who assigns everyone with special skill to a given work.

I present this story to whole world medical students, surgical assistants and interns and the next generation of surgeons who certainly have more advanced devices in their own period.

Dr. Nasser Tabesh 2014, Vancouver, British Colombia, Canada.

dr1op1