It finally happened, the case I’ve been waiting for ever since I knew I would be rotating at the area’s Level 1 trauma center – and I’ve had enough, I don’t want anything else “interesting” to happen for the rest of my week here.

We were most of the way through receiving sign-out from the night team on our five-page-long list of patients – 30% in the ICU – when everyone’s pagers started jangling at once. “Helicopter en route to MVA.” And ten minutes later, “Category 1, unconscious pt, intubated, poor breath sounds.” The chief ordered one of the residents, as well as me and another third-year student from another school who somehow landed here for the week, down to the trauma bay, while the rest of the team finished sign-out.

We ran down, and arrived to find the trauma bay in its usual controlled chaos when a patient is coming in: people scurrying around to put on lead gowns and gloves, techs checking to make sure all the iv fluids, and intubation materials, and xray plates, are ready; nurses getting their paperwork and equipment out; phlebotomists in lead gowns with baskets full of tubes and iv lines. I don’t know how it works, but somehow the nurses always have a gestalt from the helicopter team that’s not spelled out in the alert pages; and they knew this one was serious.

You also know it’s serious when the helicopter team rolls in, and the patient’s clothes are already cut to pieces. As we moved him onto the trauma bed, the helicopter nurse called out, “70yr-old male, ran into a tree, unconscious on the scene. We nasally intubated him, he has unequal breath sounds, we only got one peripheral line in, there’s something wrong with his right wrist. His belly is distended, it’s been getting bigger since we saw him. The EMTs told us they found a bunch of heart medicines in the car.”

In a flurry of activity, the lab techs drew blood, the residents at the head of the bed checked his intubation and listened to his lungs, and I put in a Foley with the attending standing over my shoulder. (The residents don’t do it so much, but the attendings definitely believe that any rectals, Foleys, etc, should be done by the student.) (There were other things happening, but my peripheral vision really shuts down under stress.) One of the residents did a fast ultrasound check of his abdomen, and reported that it was equivocal – maybe there was fluid, maybe not. Then he put a chest tube in on one side, and the chief and the other student did one on the other side. She asked him, “Where do you put a chest tube?” He said, “Fifth intercostal space.” “How far around?” “Axillary line.” So those two correct answers bought him the unexpected chance to do the tube. (I only saw at the time that she was handing this massive procedure to a ‘foreign’ student; and I was jealous. Later I heard the questions he’d answered, and he deserved it; I would have had no clue.)

Once that was done, and some air and blood had been removed, and a couple units of blood hung, the attending wanted the patient in CT as fast as possible. There, we found a hemorrhagic stroke, assumed to be the cause of the crash, as well as basilar skull fractures, cervical spine fractures, bilateral pneumothoraces, and some free fluid in the abdomen. He was taken up to the ICU. Pushing the head of the bed, I saw him moving one leg, and opening his eyes. I thought there was little bit of cognition in his eye movements; there was no time for anyone to care; but now I feel guilty for not talking to him more, then, when I think he was conscious.

In the ICU, the chief wanted two more chest tubes, apically, because of the pneumothorax that was still there. So I put one, and the other student put the other. I was sure I was going to stab the hemostat into his lung, so it took me awhile to punch through the intercostal muscles properly. (I am so amazed at the chief; she has a short manner, but any other chief I’ve met this year would have been chewing me out, and grabbing the instruments in frustration; even though she was correcting me, she still let me finish the procedure.) Once I finally got into the chext cavity, it was simple to slip the tube in after, and sew it done. So chest tubes are no longer a mystery to me.

Then, the chief did a DPL: diagnostic peritoneal lavage, while the attending stood at the end of the bed and pimped me on the reasons for doing it, and what I would look for. “So you’re looking for bowel perforation; very nice; but what are you going to order from the lab?” “Um, red blood cell count?” (Because that’s the result I heard about from the first/last DPL I ever saw.) “What is that going to tell you about the bowel? Hmm? What are you going to order?” Finally the other student and I between us worked out that one should look for amylase and bile as well. At that point the chief got her incision into the belly, and put a syringe in. She pulled out five ccs of blood, and gave us a significant look. As she pulled out another five ccs, she called to the attending, “You might want to come look at this. We’re going to the OR. Are you going to call down, or shall I?” And she waved me to clean up the tray, explaining over her shoulder that ten ccs of frank blood on DPL is diagnostic of severe peritoneal hemorrhage, and is an indication for immediate open exploration.

It took us about twenty minutes to get down to the OR, what with all the tubes draining out of that poor guy, flopping all over the place; and keeping his ventilation in order; and his right wrist being open and vulnerable; and a huge scalp laceration that, all this while, was pouring blood. Somewhere in here, the ICU staff pointed out that his family had been found, so the chief went to talk to them while the attending got him down to the OR.

In the OR, I was so nervous and excited that I managed to contaminate the tray of retractors – the first time I’ve ever messed sterile rules up so badly. I think the scrub nurse was really mad at me, but she didn’t say much, and she still helped me gown up. The anesthesiologist was, to put it mildly, not pleased with the situation of her patient. His blood pressure was hovering irrefractably around 90/50, despite all the blood and fluids he was being given, with frequent slides down lower. His O2 saturation was also not pleasing.

When the attending and the chief cut down, they found plenty of blood, and went all around the abdomen, suctioning and packing, then came back to take out the packing, and the corner were the cloths were most saturated was by his liver. So, there it was, missed on CT, a couple of liver lacerations. They got this huge fat needle with heavy chromic thread and a blunt tip, and sewed away; but there were several, one on the under-side of the liver, deep down. At one point, the chief stepped away to talk to the radiologist on the phone, and I was left as the only person at the table, as the attending was walking around. So for about thirty seconds I was first assistant; but that didn’t strike anyone, including me, as a good idea right then. All this while, his chest tube continued to drain, up to four liters in a few minutes, till the surgeons were considering opening his chest too. Then it slowed down, so we avoided that.

Finally, the attending decided they’d sutured as much as they could, and the next step would be to take him to CT angio, and see if the radiologist could embolize any other bleeding arteries. So we struggled to pack his abdomen back together, and finally managed to get enough layers of plastic over the open wound, and put a vacuum machine on over, which proceeded to suck blood out at a frightening rate. And we proceeded through the hallways to radiology, where the techs and nurses were once again shocked at the complicated case we handed to them.

As he was on the CT table, and the radiologist was just getting started, his blood pressure took another dive, down to 40/10. I couldn’t tell why he wasn’t dead already. Somewhere in here, we’d picked up from his family that he had multiple medical issues, including a bad heart valve, and was scheduled for open heart surgery later in the month. So at this point the ICU nurse who was with him, and the attending, started to get very concerned. They sent one person to find a crash cart, to get the vasoactive drugs out of, and started bemoaning the lack of a Level 1 infuser, which apparently is an IV pole that can push a pack of blood in only 90 seconds. I asked if I should get one from the ER, down the hallway, and was told yes. So I went rushing off through the hallways, lost in the maze of radiology, stopping random people in scrubs to beg for directions to the ER. Once there, I grabbed the pole, as another attending who saw me said he would warn the ER I was taking their Level 1 infuser. And I ran off back through the hallways, dragging the big pole. Very very bad form, to run in the hallway, and alarm everyone. But I was very afraid the patient would be coding or dead by the time I got back, and I didn’t want to waste time on the one thing I had been told to do. When I and the second attending arrived back, it was pointed out to me that the ER would be very very angry if I had taken a piece of their trauma equipment without telling them. So, ok; I wish people wouldn’t tell me to do things, and then tell me that I broke major rules by doing it. Anyhow, they started pushing more blood and fluids with that infuser; and his blood pressure stabilized. Whereupon his O2 sat dropped to 30%, and stayed there for three minutes while the respiratory tech checked all her equipment.

So, now he’s back in ICU, still bleeding from multiple sites, being maintained by constant doses of dopamine and epi, and frequent transfusions. I’ve resolved to donate blood the next opportunity I find, because we used so much today. And I have had my fill of “real” trauma, and getting to scrub into a case that comes running into that great big trauma room in the OR, and hunting through a huge incision in the abdomen; and I don’t want anything else to happen this week. I walked through the ICU a few minutes ago, and saw one of his daughters standing in the hallway with a kleenex box sobbing, and waving off people who tried to comfort her. He was opening his eyes and looking at me; and we did everything we could, and it’s not enough; and he’s going to die.

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