Jugular

The dark blood suddenly gushes out of the neck wound like a hot spring bubbling up from the ground. I had hardly slept the night before anticipating the complexities of operating on this man's neck. He had a mass bulging out under his right mandible which looked like a bunch of large grapes with bearded skin stretched tightly over them. The mass was smooth and lumpy and about the size of a large grapefruit.


He'd been to many other hospitals who'd told him there's nothing that can be done.

The surgery started off bad with a difficult intubation. I put the laryngoscope into his mouth only to find myself faced with a looming open esophagus and no vocal cords in sight. I pulled up with all my strength, tried repositioning the head, had someone try and push his voice box down, all to no avail. Finally, I blindly inserted the tube above where I could see the esophagus and pulled out the guide wire. As my cousin Jenny filled up the cuff with air and my cousin John attached the ambu-bag I looked for the telltale signs of vapor on the tube. Then, Jenny verified that there were breath sounds.

Unfortunately, at this time his oxygen saturation started to fall as his pulse jumped up to 172 beats per minute. I listened to his lungs and they were clamped down like a severe asthma attack. I quickly asked Simeon to give him some IV steroids and Chelsey to run to the pharmacy for some bronchodilators. It was about this time he started to grunt and clench his jaw and hands while straining like he was going to burst through some invisible barrier like the Incredible Hulk transforming himself into the Green Monster. I shouted at Simeon who quickly gave him more Diazepam on top of the Ketamine.

Finally, after about 30 minutes, we had him sedated enough, airways open enough and heart rate down enough to start the hard part of the case.

I had dissected the skin off the mass and was working my way around the lateral side underneath the tumor when I got into the jugular vein.

As the blood gurgles into the wound I quickly put my finger over it with a gauze pad between me and the large vein carrying most of the blood from the head. I pause for a moment. What do I do now? I'm definitely in uncharted territory. I calmly ask Johnny to put on some sterile gloves and hold pressure on the wound. As he holds the man's lifeblood from escaping under his finger I continue to methodically and painstakingly dissect the rest of the mass off the mandible, the voice box, the trachea and the carotid artery and other deep muscular neck structures. An hour later, the mass is out.

Johnny's fingers are paralyzed in position and totally numb.

I ask him to gently take off pressure. Blood surges into the surgical field. He quickly presses back down.


It's then I remember my old friend, Erling Oksenholt pulling me into his office in Oregon in May and showing me a short video. In the video, a gloved hand is poised over a pig's groin. A sharp scalpel suddenly lunges down slicing through the porker's femoral artery. As blood spews from the wound the gloved hand quickly piles on gauze and holds down fiercely. Then, just as quickly, the gauze is withdrawn and a white powder is poured into the wound and the gauze and pressure is quickly reapplied. A note on the bottom of the screen says "five minutes later" as the scene shifts slightly. The gloved hand releases pressure and gently pulls up the gauze. There is no bleeding.

I also remember that Erling gave me some packets of this miracle powder (Celox) that I had left with my cousin John to bring with him when he came three days ago.

I yell to Brian to run over and check the bags that he and John brought and see if he couldn't find any. Meanwhile, John and I continue to wait and hold pressure. Brian comes back at first to say he didn't find any. Jenny and Chelsey go to help him look. Finally, Brian comes back with a small, white plastic bag with Celox in big red letters. Brian opens the sack and I say, "ready" and lift off the gauze as he quickly pours in the powder and I reapply pressure. Five minutes later I lift off the guaze and see white powder in the wound but no bleeding.

Johnny has been reading the instructions and says that now I should irrigate the powder out of the wound which I do. At the end I am trying to wipe out the last fragments and the blood gushes forth again. We repeat the process and the second time I'm a little gentler.

It holds and I close the muscles and skin, wrap his head and neck in a loose ace wrap and then send him off to ICU attached to a ventilator (whoops, dreaming again). Instead, I take out his endotracheal tube and send him out to the hot, sticky wards where his family will fan him with homemade woven fans and we'll hope he wakes up and his throat doesn't swell up too much so that he can't breathe.

Two days later he's complaining of a sore throat but sitting up, breathing normally and taking liquids. His neck has virtually no swelling at all.