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Wed Jan 11 05:03:29 GMT 2006

Ken

Thank you for ensuring a lively discussion.

Tim
Dr T C Hardcastle
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)
ATLS  instructor and DSTC Cape Town Course Director
Intern program Coordinator: Surgery
Program Manager: Emergency Medicine (U.S.)
Clinical Head (Director): Diana Princess of Wales Trauma Unit
Department of Surgery Room 4064
Tygerberg Hospital / University of Stellenbosch
PO Box 19063
Tygerberg 7505
Western Cape
South Africa

2 Lorient Close
Vredekloof, Brackenfell
7560, Western Cape,
South Africa
e-mail: tch at sun.ac.za
Cell: +27824681615
Office: +27219389281 or 4911 pager 0302
Home: +27219813098

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of KMATTOX at aol.com
Sent: Wednesday, January 11, 2006 6:59 AM
To: SURGINET at listserv.utoronto.ca; trauma-list at trauma.org;
ccm-l at ccm-l.org
Subject: # 11 Autopsy

First:  I am very proud of the power of the internet.    Dozens of persons 
have made repeated comment on the 10 installments of this  case.    Many 
differing suggestions were made, and all were  possibilities, acceptable 
possibilities, within the data that I gave  you.     The great value was the variety of 
dialogue and  everyone learned a little bit different from this case.   It has  
contained surgical, ethical, economic, ICU, paramedic, nursing, 
administrative,  and OR management challenges.     Thank you for your  interest and 
participation.   

Second, this is a difficult kind of case which looks better for a few days,  
and then just crashes.    Each of us have experienced such swings  in mood.    
It is an ego trip to present successes, but we must  also learn from cases 
where the results were  unfavorable.      

I was expecting to see a protal vein thrombosis or mesenteric artery  
embolization or thrombi at the autopsy.   Neither was  present.   What was found were:

1.    Healing secure T tube in esophagus.    No real mediastinitis
2.    Significant inflammatory reaction and rind in  BOTH pleural spaces,
3.    Intact, healing groove in the posterior left  ventricle
4.    Right sided pneumonia - 
5.    Fatty, early cirrhotic liver
6.    Dead small bowel, with no vascular  occlusion
7.    NO aortic thrombis

The pathologist suggested infection in pleural spaces, low flow states,  
sepsis all contributed to the low flow to the intestines.    They  and several 
members suggested that the jejunostomy feedings had some  contribution to the 
dead gut.   I would agree, but do not fully  understand the mechanism, all of us 
have seen it.   

I have no "smoking gun" easy explanation for his dead  bowel.    

I would be happy to see additional discussion as to what could or might  have 
been done different.    I have not addressed the family  situation here as 
that was covered in an earlier post.     

Thank you for allowing me to share this case with you.  

k
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# 11 Autopsy