It ain’t bleeding until you can hear it bleeding

Bleeding is upsetting. At least, that’s what I’ve been told. I mean, I have noticed that many people have visceral reactions to the sight of bleeding, or even just blood. People who pursue a career in surgery generally do not have this kind of reaction, and I find it interesting that it can distress some individuals while others are not at all bothered by it.

This might lead you to assume that surgeons have some altered brain chemistry from the average person (and this is possible) and that they just don’t react to the sight of someone who is injured (sometimes, depends on the injury), and that they just don’t care about the people around them. (Absolutely untrue!)

I have no data to comment on the first supposition, so I’ll just leave it alone.

I have children who are routinely injured, and so I can say that surgeons do react to injury, but we set the bar higher than the average person for injuries that will make us react, whether through action, or emotional response. Every mom knows that little kids will get the tiniest scratch and flip out, insisting on a Band-Aid. Once they’ve learned the power of the magical Band-Aid panacea, even bruises need Band-Aids. Every mom knows you have to hide the Band-Aids where the kids can’t reach them, or you will come home every day to a depleted Band-Aid supply and a Band-Aid-mummified kid.

I am not insinuating that bleeding is an insignificant injury, or that people who are upset by bleeding are overreacting or histrionic, necessarily. They are normal people, whereas surgeons are different.

A surgeon sees injury and assesses it in the context of our profession: Is it insignificant? Easy to fix? Hard to fix? Impossible to fix? Most bleeding we see fits into categories one and two, sometimes three, and very rarely, four.

There is a well-known quip in surgical circles, that for orthopedic surgeons, it ain’t bleeding until you can hear it bleeding. This stems from the fact that bleeding is pretty common in orthopedic procedures, and that orthopedic surgeons are generally pretty focused on their goal (fixing the bone) and less attentive to peripheral events (such as bleeding).

There are times outside of orthopedic surgery and gunshot wounds when bleeding is profound and catches even my attention.

Some years ago, I remember being stat paged to the emergency department, and arriving at a scene in the trauma room that could have been the site of a mass murder. There was literally blood everywhere. The person on the gurney was sitting bolt upright, a bright red towel smashed against his face, and people with widely dilated pupils running around frantically. First impression: bad. My heart rate: 80.

I put on a gown and a mask with a face shield (don’t want any of that in my eyes, not knowing what I’m getting into) and gloves, and waded into the bedlam.

The man on the gurney looked gaunt. Second impression: really bad. My heart rate: 100. Some underlying disease process that has been at him for a while, and he looks like he’s been losing. The emergency medicine doctor filled me in on the short story: The man had been treated for a cancer of his jawbone that had recurred, and his tumor was incurable and unresectable. Third impression: incredibly bad. Maybe impossible to fix. My heart rate: 110.

I talked briefly with the emergency medicine doctor: Did we have blood coming? Did we check coagulation bloodwork? Platelet count? Did we give Vitamin K? Let’s do everything possible to stop this bleeding.

I explained to the patient who I am, and that I had to see what was under the towel to determine whether I could fix it. Perhaps there was some single spot that I could put a stitch into that would stem the tide.

When I drew back the towel, I found necrotic (dead, rotting) cancerous tissue with blood coming out of it, impossible to see an exact source. My heart rate: 120.

I took my finger and pressed directly on the bleeding necrotic tissue. And … it seemed to control the bleeding.

Well, that was good news. Heart rate back to 90. However, the next step was problematic. I did not have a head and neck surgeon around to help me in the OR, and even if I did, we’d be talking about trying to take out a section of this man’s jaw, back to clean healthy tissue that did not have cancer in it, and could be sutured or cauterized to control bleeding. Not feasible.

If I let go of the hole, he bleeds again. Also not a palatable choice.

But then, there is the last variable contributing to miracles: time. I stood there with my finger in the hole for 20 minutes. In bleeding, the biggest mistake, when you have control of bleeding, is failing to use time in your favor. Don’t rush. Wait.

What you wait for, in addition to getting all your tools and supplies ready to tackle the problem, is the magic of all the wonderful things in your body that make blood clot. The platelets and clotting proteins get all wound up to form a matrix that is impervious to liquid blood — a clot — and next thing you know, the bleeding is controlled.

The other thing that sitting there waiting will do, is the frantic bedlam passes. It seems that people in a panic have trouble sustaining it for longer periods of time. (Surgeons included.) And so, about 20 minutes later, we were all prepared for the blood to start spurting out again, and we were all psychologically prepared to contemplate how to cross the bridge that we had come to, and I took my finger off the hole. And …

Nothing. It had stopped.

It doesn’t seem possible, that bleeding like that can just stop, and yet, it stopped.

The poor man had won another … hour? Day? Week? Who knows? Whatever he got, it was better than the alternative.

And so, when I’m faced with a novice in the operating room, or any other situation where there is bleeding, and the novice declares what is already obvious (“Doctor, it’s bleeding!”), I just smile to myself, and think, “It ain’t bleeding until you can hear it bleeding.”

“Hope Amantine” is a surgeon who blogs at Simple Country Surgeon.

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