Reserve

Physicians often talk about young, healthy patients having "lots of reserve," and frail, elderly patients with "little reserve." This is best illustrated by a case I saw recently. A 25 year old is involved in a car accident, found to be confused and hypotensive. In the emergency department, despite 2 liters of fluid, his blood pressures are still 90/30. An ultrasound exam of the abdomen shows free fluid, and he is brought up to the operating room for exploration of the belly. Multiple anesthesiologists work simultaneously to secure the airway, obtain arterial access, place large bore IVs, give antibiotics, maintain blood pressure, deliver anesthetic, send labs, transfuse blood, and chart. When the surgeons open the belly, blood pours out. It's difficult to see where the bleeding is coming from, and methodically, they examine the likely culprits. The spleen is hemorrhaging, and the way to save the patient is to clamp the vessels and take it out.

I don't know how much blood loss there was, but it was impressive. Nevertheless, after initial resuscitation with fluid, some blood, and some plasma, the patient was able to maintain a reasonable blood pressure and heart rate. The 25 year old patient can tolerate this. A similar injury in someone three times his age would have likely been fatal. This reserve, the ability for the body to compensate for disastrous physiologic disturbances, is impressive. It is the reason why the young caveman survived a fight with the saber tooth tiger or a strenous childbirth. Even though we like to think our anesthesia or surgery saved the patient, it is the patient that saves himself.