Last night Dr. Mark was called regarding a young man, who with his brother was shot in a crack house, apparently over a drug deal gone bad. This particular fellow got shot through the face and neck, fracturing at least one part of his mandible, and requiring repair and general exploration. His brother was unstable, and spent most of the night in the OR (I don’t know how that turned out), so our patient didn’t get to surgery until this afternoon.
He was a prime example of the law of inverse proportionality: the more useless a member of society is, the less likely they are to be seriously injured by any major trauma that happens to them. The bullet had managed to go through one mandible, straight through the root of the tongue, and out into the neck (not all the way out) without disrupting his airway, carotids, or major nerves. The trauma surgeons obviously had difficulty believing this, and got multiple CT scans of his neck. Even so, the exact injuries were not clear until Dr. Mark bravely pulled out all the gauze that had been packed around the ET tube to control the bleeding, and started poking around.
The patient was HIV positive. This is the first time I’ve scrubbed on a case where the patient was known to have HIV; I’ve been in Hep B and Hep C cases before, but not HIV. Everyone who helped to move the patient was meticulously gloved (unusual), and we all double-gloved for the surgery, and were very conscious of where the needles were. Dr. Mark was eager to avoid putting arch bars in, because those sharp wires would be just begging for someone to get stuck.
Some attendings encourage medical students not to scrub on cases where the patient is known to have either hepatitis or HIV, for two reasons: the medical student doesn’t really have any clinical responsibility, so they’re not obliged to be there; and medical students are most frequently stuck, because they’re standing with their hands in the field, between the surgeon and the scrub tech, and we don’t always know what we’re doing. Dr. Mark offered not to include me, but I didn’t take him up on it. If I want to do surgery, then viruses are an occupational hazard. God is in control; and the only thing to do is to use as many precautions as possible, and not worry about it after that. Also, I’ve been thinking (especially around Dr. Mark, arguing about the morality of war): my worldview includes many dangerous precepts, but I haven’t had to act on any of them yet. For example, it’s remarkably convenient to be a proponent of wars in general, and this war in particular, and also to say that it’s wrong for women to be in the military; that’s really not why I hold those positions, but it’s undeniably convenient. This surgery is one of the first places where I can do something dangerous because I think it’s right. A small step, but in the right direction.
Dr. Mark let me try to imitate his meticulous suturing techniques on the entrance wound. Then after he’d finished sewing the tongue back together and picking fragments of bone out of the mouth, he let me make an incision right over where the bullet was lodged under the skin of the neck, and fish it out with a hemostat, and sew that incision, too. Great opportunities; I discovered tha three months of not practicing has definitely eroded my suturing abilities. There are still five months till I’m a surgical intern; I’m going to be all thumbs again by then.
The conversation during the case involved an unusual kind of pimping: Rather than, “What artery is here?” or “What nerve innervates this area?” we somehow landed on the trial and execution of Michael Servetus. I think I unwisely teased Dr. Mark by telling him that my brother had just purchased a pistol, and we were all very proud of it. This exhibition of violence by Christians (Presbyterians, at that) led him to Zwingli having died in battle, and thus naturally to Servetus being burned for a heretic in Calvinist Geneva, and questions like, “Who was Guillame Carrel?” and “Who was Sebastian Castelio?” I unsuccessfully attempted to defend Calvin’s personal involvement in it, and ended up having to retreat with a promise to research the question over the weekend. The nurses were vastly entertained.