Crash: Intervention - text only -

• David's case: haematoma

• Laura's case: ruptured spleen

The body has a remarkable ability to heal itself. But sometimes it needs help.

• David's case: haematoma

For instance, a large haematoma that compresses or shifts the brain may damage structures in the brain stem, threatening the areas that control breathing and the heartbeat. A haematoma may also raise the pressure inside the skull, eventually cutting off the blood supply to the brain. In such cases there is nothing the brain can do to save itself. If the individual is to survive, surgeons must intervene to remove the clot.

But how do doctors know that a blood clot is threatening a patient's life? Respiratory difficulties and cardiac arrest may indicate a blood clot, but they may indicate a number of other problems. However, there is one revealing symptom: if one of the pupils is dilated, this may indicate that pressure on the brain is crushing the nerves in the eye. This is what happens in David's case.

Clearing a brain haematoma
Once doctors have shaved the patient's scalp, there will be a tell-tale bruise indicating the area where the bleeding is occurring. Mannitol, a drug used to reverse acute brain swelling, is injected into the blood stream to draw fluid out of the blood vessels and relieve the pressure on the brain.

Doctors must then drill a series of small holes in the skull and remove the area of bone in between the holes. Through this gap, they will be able to clear the clot, relieving the pressure on the suffocating brain cells. Although the extent of the damage caused by a haematoma may still be severe, surgery removes the immediate threat to life.

• Laura's case: ruptured spleen
In the case of a ruptured spleen, the brain takes the wrong action when it tries to repair the damage. Suddenly deprived of blood, it instructs the heart to beat faster in order to increase blood flow. But the blood simply pours out of the ruptured organ, reducing the blood supply to the brain even further. In such a case immediate surgery is needed to keep the patient alive.

Finding the wound
Laura's abdomen is opened. She is bleeding out very rapidly, and her brain is kept alive only by the external supply of blood being pumped into her system. The surgeon has only moments to find the rupture, and with blood gushing from Laura's system, this is no easy task. He has to find the wound by touch.

Once the wound has been found and the artery clamped, the effect is immediate: blood flows back to the patient's brain within seconds. Laura's life is no longer threatened.

The surgeon has then to make a choice: to perform a splenectomy (removal of the spleen) or to repair the spleen, which is a more risky operation.

Splenectomy
The removal of the spleen is not an overly complex operation, and patients may spend as little as a week in hospital. But the aftermath of splenectomy is with the patient for life.

Removing the spleen weakens the immune system, making the patient vulnerable to infections, which can be serious if not dealt with quickly. Long-term antibiotics must be prescribed.

One post-splenectomy patient, whose sons have also had to have their spleens removed as a result of disease, describes life without a spleen: 'We all live without symptoms, but we are all prone to infections, we sleep to excess and have enormous trouble waking in the morning. This is to the point that we just don't function until late morning and feel like we have hangovers.'

Repairing the spleen
Repairing the spleen is therefore preferable in the longer term, though there are risks of further rupture. The surgeon must remove the damaged part of the spleen, sew up the rest of the organ and remove the clamp from the artery. If the new seal on the spleen holds, the operation will have been a success.

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