Doctors: Carl Pavano Nearly Died from Ruptured Spleen

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Doctors: Carl Pavano Nearly Died from Ruptured Spleen
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On Jan. 12, pitcher Carl Pavano, currently a free agent, slipped while shoveling snow and suffered a ruptured spleen. According to Joe Christensen of the Minneapolis Star-Tribune, the seemingly minor tumble almost proved fatal.

As Christensen states, Pavano didn't think much of the fall at the time.

"It knocked the wind out of me," (Pavano) said. "I didn't think anything of it that weekend. We were out on snowmobiles and sleds with the kids. We were building snowmen."

Two days later, (he) went through a full workout.

However, Pavano's condition took a drastic turn for the worse four days after the fall. Christensen continued:

On Jan. 16, Pavano went for another workout in Westchester. Riding to the facility, he felt a sudden wave of abdominal pain and nausea.

"My body just went into shock," (Pavano) said. "I turned white. It was one of the worst feelings I've probably ever had."

Hannah Foslien/Getty Images
Carl Pavano's injury history is extensive.

Three days, three hospitals, a collapsed lung and one emergent surgery later, Pavano narrowly survived what anyone in the medical field would deem a close call—he nearly died.

Thankfully, it appears he is now out of the woods and focused on recovery—the best possible outcome of the frightening sequence of events.

Wait a second, what? He slipped while shoveling snow and nearly died as a result? How can that be possible?

Believe it or not, upon examination of the reported mechanism of injury, it actually makes sense. That said, it should be emphasized that the following merely represents educated speculation, as exact medical details are—as always—unavailable.

With that in mind, let the anatomy lesson begin.

According to Christensen, Pavano did not slip and fall down. Rather, he partially lost his balance and fell onto the upright handle of the shovel he was using. As he is certainly much taller than the shovel, he likely jammed the shovel upward into the left side of his abdomen and under his left rib cage.

That's the spleen's territory.

Location of the spleen within the body. Photo from Wikimedia Commons.

One of the spleen's primary functions is to help the body fight infections. It is especially important in fighting certain bacterial infections. That said, it is not necessarily for survival, and countless people live entirely normal lives after having it surgically removed for one of any number of reasons.

Usually, the lowest three left ribs protect the spleen from direct hits. Nevertheless, an upward-angled blow to the left side of the abdomen can sidestep that protection by going under those ribs. In other words, nothing but soft tissue sat between Pavano's spleen and the shovel handle, resulting in direct trauma to the organ.

However, that is only the beginning of the story.

Via the splenic artery—one of the largest arteries in the human body—the spleen receives approximately 10-15 percent of the body's blood supply all by itself. If any of the blood vessels within the spleen are broken for any reason, that massive blood supply turns into internal bleeding.

Ronald Martinez/Getty Images
Jason Witten—tight end for the NFL's Dallas Cowboys—suffered a lacerated spleen during the 2012 preseason.

Bleeding from splenic injury can range from slow and smoldering due to a small laceration—like the case of the NFL's Jason Witten—to immediately life-threatening following frank organ rupture. As Pavano now knows, one can turn into the other, as well.

Due to the important, though not vital, immune function of the spleen, doctors usually try to allow it to heal on its own following less-serious injuries. As Christensen reports, that was the case with Pavano—even after things first started to look concerning:

"I was in good shape, so my vitals were strong," Pavano said. "They didn't feel the bleeding was proficient enough where we needed to rush into surgery. I got into the hospital on a Wednesday, and I was just deteriorating every day, little by little."

Unfortunately, the spleen, an already fragile organ, is even more vulnerable when it is injured and the progression of a smaller injury to a life-threatening one is very possible.

A ruptured spleen represents as big of a medical emergency as they come. Though it can sometimes be repaired, the injury usually requires either a splenic artery embolization—surgically blocking the blood vessel—or a total splenectomy.

Sometimes, a spleen can be repaired rather than removed. In this video, bleeding vessels within a spleen are cauterized.

It also requires it now.

Policy differs from hospital to hospital, but usually an on-call general surgery or trauma surgery team is assembled, and the operating room is prepared as the patient is being transported to it.

Luckily, doctors identified the gravity of Pavano's situation in time—a difficult task in and of itself. CT scans and ultrasounds are only so good at identifying severe internal bleeding, and the abdominal compartment can silently hold an amazingly large volume of blood.

In Pavano's case, the blood may have gone somewhere else, as well. He may have also had a partially ruptured diaphragm.

The left half of the diaphragm—a thin, flat muscle that somewhat resembles a horizontal piece of paper lying on top of the abdomen—sits immediately above the spleen.

If the shovel handle forced itself far enough into the abdomen to rupture Pavano's spleen, it is reasonable to guess that it also tore part of the left half of his diaphragm, creating a connection between the normally separate abdominal and chest cavities. As the diaphragm is essential for breathing, an injured diaphragm also explains Pavano's feeling of getting "the wind knocked out of (him)."

Location of the diaphragm in the body. The spleen sits immediately underneath the left side of the diaphragm. Photo from Wikimedia Commons.

If his diaphragm did, indeed, rupture, Pavano's spleen could bleed not only into the abdominal cavity, but through the tear and into the chest cavity, as well. As blood accumulates within the chest, it can force a lung to collapse—called a "hemothorax"—as it did with Pavano. Christensen mentions that doctors needed to remove over six liters of blood from the chest cavity before performing a splenic artery embolization to stop the bleeding.

In short, it appears likely that the shovel handle not only caused a medium-sized cut in Pavano's spleen, but also partially tore his diaphragm. His body then compensated for the bleeding—slow at first—as the blood accumulated in his abdomen and chest over the next few days. Then, when the amount of blood lost became large enough to cause a hemothorax and shock, his condition began to spiral downhill—fast.

According to Christensen, at one point doctors warned Pavano how bad it had gotten. "I was hours away from going into cardiac arrest and probably wouldn't even be here," Pavano told Christensen.

Fortunately, it appears doctors intervened just in time. By evacuating the blood from Pavano's chest, doctors allowed his collapsed lung to re-expand, and by performing a splenic artery embolization, they stopped the source of the bleeding. After then removing the spleen entirely, his medical team ensured this would never happen again.

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They also saved his life.

Consequences of hemorrhagic shock range from the minor and reversible to the permanent and debilitating, and details regarding his recovery will likely continue to surface over the coming weeks and months.

Though Christensen reports that he wants to pitch again, Pavano is going to defer figuring that out until a later date.

"Right now, that's the last thing I'm worried about," he said. "It's been a crazy few weeks."

 

Dave Siebert is a medical/injury Featured Columnist for Bleacher Report who will graduate from medical school in June. He plans to specialize in both Family Medicine and Primary Care (non-operative) Sports Medicine. Injury and anatomical information discussed above is based on his own knowledge.

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