Patient Case Review: Dr. Audrey Lim (#2)

Audrey Lim was a stabbing victim in episodes 5×18 Sons and 6×01 Afterparty.

After helping her friend nurse Dalisay Villanueva getting out of a bad domestic abuse situation, Audrey inadvertently becomes one of the targets of Dalisay’s controlling boyfriend Owen.

On the day of Shaun and Lea’s wedding, Owen disguises himself as a flower delivery man to gain access to the hospital where he hides in the break room and attacks Dalisay with a knife to retaliate for her leaving him. Audrey happens to enter the break room just after Dalisay was stabbed, and Owen, having hidden in a corner, attacks Audrey, too.

She gets stabbed twice (in the abdomen and the chest) and passes out initally but comes to again and tries to help a bleeding Dalisay who is lying next to her. With little strength left, she can’t do anything and loses consciousness from blood loss.

After the hospital goes into lockdown, Shaun, Jordan and Lea find Audrey and Dalisay in the break room and try to stabilise them as best as possible. Shaun diagnoses cardiac tamponade upon finding her on the break room floor. Glassman, Andrews and Jerome enter the scene shortly thereafter, Shaun and Glassman manage to extract the fluid around the heart, initially stabilising Lim before they can transport her to an OR to perform emergency surgery.

During surgery, they discover the full extent of the injuries: lacerations to the pulmonary hilum, a small cut to the left ventricle, grade four liver laceration with active bleeding into the peritoneum. In order to stop the liver bleed, Dr. Glassman suggests a partial resection of the liver, which Shaun is not in favour of since it would decrease Lim’s life expectancy by 10 years. Shaun suggests angio-embolization instead. There is a high risk that Lim would need a major blood transfusion, which they don’t have access to because of the lockdown.

Glassman has to leave the OR to tend to Dalisay and instructs Shaun to cut out the damaged lobe of the liver. During the surgery, Shaun discovers that the bleeding is confined to an aberrant vessel and they can stop the bleed through angio-embolization after all, so he decides to move ahead with the embolization without informing anyone of his decision.

After Shaun starts the procedure, Glassman comes back to the OR and reprimands Shaun for having chosen the embolization over his suggested approach of partial resection. Shaun explains that parameters changed while Glassman was away, so he adjusted the course of treatment.

Knowing that it they are now too far into the embolization procedure to safely reverse course, Glassman agrees to go ahead with the embolization. Audrey’s blood pressure then drops dramatically from a bleed in a collateral vessel. (Collateral vessels are those connecting the aorta, i.e. the main artery connected to the heart, with the pulmonary artery.) Shaun thankfully manages to stop the collateral vessel bleed.

Please note that the spinal cord injury was indicated to be a result of the drop of overall blood pressure during this collateral vessel bleed. It does not have anything to do with the lack of availability of the bypass machine later on.

Lim wakes up after the surgery, but after a brief period of alertness, her blood pressure crashes. Shaun uses ultrasound to diagnose a ventricular septal defect (VSD), which he suggests to fix with a GORE-Tex patch. There is only one bypass machine left they can operate, which is also needed by Owen who was shot by the SWAT team. Andrews decides that they can fix the damage to Lim’s heart with an occluder device for percutaneous closure which wouldn’t require cardiopulmonary bypass.

They try to place the occluder device but Lim goes into pulmonary heart failure. They try to position the occluder device correctly, and Shaun realises that they were missing a second VSD that they need to fix with a second device that is angled posteriorly. This stabilises Lim so that she survives.

Lim regains consciousness the next morning, but is concerned that she can’t feel her legs. While Dr. Andrews first theorizes it may be post-surgical myopathy, they find that Lim can’t move her legs at all and it appears she is paralysed.

The paralysis, as it turns out, is not temporary, and an investigation into the case outlines that the paraplegia was caused by lack of oxygen when Audrey’s blood pressure dropped and there was a temporary loss of blood flow to her spinal cord which caused nerve damage. The investigation also determines that causality between Shaun’s chosen angio-embolization approach and the paralysis was inconclusive.

Controversial discussions of the situation bring up many questions, such as would the outcome for Audrey have been different or better if they’d gone with Glassman’s suggested approach of partial liver resection? There are no good answers here since no one can know what would have happened if the surgery had gone differently.

Audrey returns to work 14 weeks after the assault in her position as Chief of Surgery, now bound to a wheelchair and trying to adjust to this new and challenging situation.