His hand if not life was gone - Our Team effort saved both.

11th March 2014 will always haunt Amar (name changed)  as a nightmare for the rest of his life . This young carpenter was on his regular work when accidentally a Marble Cutter pierced his right hand  in such a way that the only connection between his hand and the rest of his body were parts of skin and few surrounding tissue , this immediately led to massive blood loss and the patient was in Shock. Under normal circumstances these hands cant be saved unless a vascular surgery is done but the patient was almost dead-any surgery in such patients are very risky! 

Background 

Limb Saving vascular Traumas are of frequent occurrence in War Medicine, extremity amputations  due to vascular injury were the most frequent procedures done by US surgeons in  the  second World War .  DeBakey et all calculated that during second world war  amputation rate was higher than 40% among survivors  ,60% died . However lot have changed since then , the earlier notion of saving “life over limb “ has been replaced by “saving Life and limb “  .However   the  simplicity of the concept ends at “ saving life and limb” caption complexity and challenges  of this concept  from step one haunt the most  renowned trauma centres of the world.

We had three main Tasks  1 To immediately stop bleeding   2 bring him  out of Shock   3  Immediate vascular surgery which may save his hand , in spite of being in a state of shock  .

Case Discussion 

The patient was brought to the ED 30 minutes following the incident , during this time his BP was un recordable and there was profuse bleeding from visible right brachial artery  below his right elbow . There was a visible open  fracture of the forearm . The Emergency Team  led by Dr Indraneel  Das Gupta( Emergency Director ) started its resuscitation  efforts  based on the principles of Damage Control Resuscitation (DCR)  , a second team led by Dr Sudeshna Barua (Consultant Emergency Physician ) and Dr Syed Mudassir focused on immediate control of bleeding using temporary measures  , the third  Orthopaedics team led by Dr Somnath De and Dr Nikhilesh Das   focused on the aspects of the injury  while a fourth team of Vascular Surgeon  led by Dr Ashim Kumar De and Dr Hasim De was summoned for immediate vascular surgery in the Emergency Operation Theater . The Emergency Team managed to bring the blood pressure back to a recordable range and temporaryly stop the bleeding though the patient was still in shock .  This paved the way for further intervention -crucial decision was taken that the patient will undergo vascular surgery while resuscitation measures are still going on because that was the only way to save his right hand and arguably his life .
The Vascular Surgeon Dr Ashim Kumar De performed End to End Anastamosis of Right Brachial Artery and bifurcation of Radial and Ulnar  arteries .  The Anesthesia Team maintained the patient in a stable condition during the surgery.


The operation was successful ..His hands were gifted back by the Vascular Surgeon and his life was saved  by the Emergency Team , the Orthopedics team repaired the fracture and injury, as a result of these   pulses were palpable  in the right  hands after the surgery and the patient was able to move his finger. Equally important role was played by the Emergency Nurses and Paramedics ,without their help all  plans would have never been implemented.
This was  a great example of successful  Team  effort  which played against all odds to save the life and hand of the poor carpenter .

NB : Clinical images showing  initial condition of the patients hand after the traumatic incident has not been  displayed as we believe its  un-ethical to display such a pathetic  and terrifying image online.