Our collaborator the Dr Alain Vadeboncœur, emergency physician and full professor at the University of Montreal, is medical advisor for the show team STAT. Here he draws on plotlines from the television series to provide more in-depth insight into some of the illnesses diagnosed on screen.
Spoiler alert: don’t read this if you haven’t watched this week’s episodes of the show yet STAT !
The heart is a pump, yes. But to pump, there must still be something to propel. And obviously, there was no more blood to circulate in the heart of Gabriel Lemaire’s character in STAT this Thursday, because he was suffering from what is called a “tamponade”.
This problem represents a serious, but rare emergency, which always requires a quick intervention carried out with an expert hand. Let’s see what it’s all about, or rather what turned Gabriel’s heart in this way.
The history of pumping
That the heart pumps blood is a well-known notion, even if we hesitated for a long time on the real circuit of blood circulation. It was by two famous doctors of their time that the phenomenon was once confirmed.
First by a remarkable Syrian doctor, Ibn al-Nafis (1213-1288), who rejected the erroneous hypotheses persisting since the beginning of the previous millennium, in particular those of the Greco-Roman doctor Galen. Except that his work would sink more or less into oblivion until his rediscovery in 1924.
On the western side, it was in 1616 that the great English physician William Harvey aptly described the complete circulation and, above all, demonstrated the decisive role of the heart in this immense work of receiving blood, then propelling it – to make it circulate, therefore. Except that to propel, the heart must first fill up, which is not guaranteed!
An upstream problem
Basically, the filling of the heart is a phase as important as the ejection of blood, a pump can only offer what it receives.
After cardiac arrest due to arrhythmia, which requires a shock to restart the heart, and pump problems which render propulsion inoperative, the most frequent cause of cardiac arrest remains a critical filling problem, which may be due to factors very varied.
Even if Gabriel did not suffer first neither arrhythmia nor any disease of the heart, which could have interrupted its beats, his condition suddenly worsened, because his heart was no longer receiving enough blood.
In such a case, several causes are possible. For example, if there is not enough blood left in the body for the heart to swell, it will have nothing to circulate.
This is what happens in a situation of major bleeding, whether internal, as during a trauma, or external, in the event of an injury leading to visible bleeding: bleeding from the digestive system, the lungs or, rarely, of the bladder. Extreme dehydration could also lead to such a state of shock.
In these cases, the treatment is “simple”, when the necessary resources are available: replace the lost fluid or blood and fix the problem at the source.
An obstacle to filling
To send blood to the lungs in the “small circulation”, the right heart must fill up. To irrigate the whole body, via the “great circulation”, it is on the left side of the heart that the filling is important.
In addition to situations where it is the “filling” fluid (blood) that runs out, other serious contexts explain that the heart cannot be filled, even if there is enough blood in circulation, in particular on the left side.
Tamponade is a good example of these dramatic situations where the left side of the heart can no longer propel blood because there is no more. This is exactly what happened to the character of STAT.
It must be understood that the heart is not free in the thorax. It is rather very well surrounded by a thick, resistant and fairly inelastic membrane, called the pericardium, which ensures its stability and protects it. Between the pericardium and the heart it contains is a little liquid that facilitates the movement of the heart, as if it were a lubricant.
Except that our pericardium also has the defects of its qualities: its fibrous wall cannot distend easily and if liquid accumulates there quickly, it will not be able to accommodate it without compressing the heart, crushing it in a way. Hence the term tamponade.
How does the pericardium fill up like this? This can be due to different causes. In the case of the character of Gabriel, the bleeding in the pericardium was caused (delayed) by the trauma.
Such a situation sometimes arises from a complication following a heart operation. In other cases, the fluid is secreted from a metastasis in the pericardium.
In other, more common contexts, the accumulated fluid is not blood, but rather inflammatory fluid, such as is frequently seen in pericarditis, a usually viral inflammation of the lining of the heart.
Decompress the heart
The faster fluid builds up in the pericardium, as in sudden bleeding, the greater the risk of tamponade, and the more urgent the situation becomes. Everything can unravel.
If the fluid accumulates, the pressure in this cavity quickly increases, then exceeds the normal filling pressure of the heart, which compromises the arrival of blood there. The heart then pumps more or less in a vacuum, even if the brain commands it to speed up as much as possible to compensate.
The quantity of blood ejected with each beat then collapses, thus the cardiac output, which no longer allows irrigation of the brain and the other organs thus affected. The result is a reduced state of consciousness and a state of shock, even cardiac arrest.
At this end, there is only one solution: to remove the guilty liquid from the pericardium and prevent it from returning there. If the situation is less urgent, this can be done using a simple needle. In case of acute tamponade related to traumatic bleeding, as in the episode of STATopening the thorax becomes the only option, and it is sometimes a matter of minutes that requires action on the spot.
all ends well
Surgeon Isabelle therefore performed a thoracotomy, performed here at the patient’s bedside. She opened the thorax with a scalpel, inserted a “retractor”, then did the same with the pericardium, in order to evacuate the blood which was there.
She was also able to remedy the cause by performing a point on a blood vessel. In life, even in an emergency situation, the patient is generally transferred to the operating room so that a drain can then be installed to allow the continuous outflow of blood, before closing everything.
By the way, this very contemporary episode plunges us back into history, when in 1893 the American surgeon Daniel Hale Williams (1858-1931) chose to explore a knife wound threatening the life of a man named James Cornish.
The knife having touched the pericardium, the surgeon also opened the thorax and succeeded in stopping the bleeding by placing a point, this one in the pericardium. This event is considered nothing less than the very first heart operation in the history of medicine.
