The tragedy involving Pramod Mahajan has led to numerous queries from friends and patients on the management of major abdominal injuries. I realised then that the media, especially the TV media, gave the impression that severe liver trauma is managed by liver transplantation. An impression has also gained ground that liver transplantation is not being done in India and that doctors have to be called from abroad to deal with major liver trauma.In fact liver transplantation is now being done routinely and very successfully in India. But there are other issues thrown up by the Mahajan case that need clarification. For instance, I was unable to convince a senior correspondent of a national daily that while liver transplantation was not necessary in a case like this, the expertise of a liver transplant surgeon may be helpful in controlling bleeding from the liver. I felt compelled, therefore, to clear some misconceptions that may have been conceived during the course of the sensational media coverage accorded to the Mahajan case.In the UK, it is mandatory for most surgeons and anaesthetists to do the advanced trauma life support course. Just to briefly highlight the basics of caring for a trauma patient, I will draw heavily from what is taught in these courses. The management of trauma is done as a very well-practiced drill. Paramedical staff and ambulance are available on dialling the emergency services numbers. These paramedical staff can provide many of the initial first-aid measures. Following injury of any type, the upper airways must be secured and protected. The term “upper airways” refer to mouth and windpipe. The blockage of these airways will result in quick and sudden death, so they need to be cleared immediately. Following this, the threat to life is by injury to the lungs. Accumulation of air or blood in the chest cavities will impair breathing. A chest tube may need to be inserted promptly. The above two procedures are the ‘A’ and ‘B’ of trauma management. In trauma care, a life is saved or lost by the care given in this “golden hour”.We now come to the ‘C’ of trauma management. This refers to circulation and an attempt must be made to stop bleeding quickly. Although one can replace all the blood that is being lost by transfusion, the consequences of massive blood transfusion are horrendous. With ongoing blood loss, the individual becomes cold, body fluid pH turns acidic and both these factors results in the inability of the blood to clot, thereby worsening body physiology. This adverse set of events will result in more bleeding. Further, if bleeding is not controlled quickly, there may be disastrous consequences on the kidney and in the lungs. The kidneys will pack up at least temporarily because of the acute damage and cell death of the tubules. The lungs become stiff, oxygenation is impaired, leading to prolonged and sometimes irreversible dependence on the ventilator. This condition is called Adult Respiratory Distress Syndrome.The concept of damage control surgery is now becoming increasingly popular. What this means is that following trauma one must quickly stop the bleeding and get on top of any other factor that threatens life immediately. Surgeons know that simply stitching the hole in the colon will not work in the long term. However such stitching will carry the patient through the next few days when a repeat operation for more definitive repair can be undertaken.A nation’s health is tested by numerous public health indicators, such as infant mortality figures, the average life expectancy and the maternal mortality rate. In a developed society, the level of trauma care is another index. Trauma effects individuals in the most productive years of their life. How quickly the patient is shifted to a trauma centre, whether the centre is ready to receive the patient, and in which order the injuries are dealt with, will decide the fate of the trauma victim. Obviously the priority is on the injuries which threaten life immediately.The transplantation for liver trauma has never been done. There is of course the theoretical possibility that a badly bleeding liver can be removed after clamping the hepatic artery, portal vein and the hepatic vein. On the back table, the bleeding part of the liver can be resected and then rejoined in the body. This process is akin to transplantation and can be termed as auto-transplantation. However this is a mammoth exercise and, as and when it is done, will make medical history.While transplantation in the context of liver trauma is irrelevant, liver transplantation as a surgical intervention needs to be encouraged in every region of the country. That will equip surgeons to deal with badly damaged livers more successfully. One final word, liver transplantation will get a boost if more cadaveric organs are donated. The practice of organ donation must be popularised in this country.The writer is a senior surgeon, Gyan Burman Liver Surgery Unit, Sir Ganga Ram Hospital, New Delhiguptasubash@hotmail.com
