Thursday, September 1, 2011

How to Save a Life

It's not everyday that we get reminders of why we agreed to work 80 hours a week and 30 hour shifts to "someday" have a better paying job with more freedom. Like most residents, I'm pretty jaded. Most days I'm convinced that 75% of our patients are really just a drain on the system rather than real people needing real help. When it comes to trauma, the rule seems to be dealing with jerks who were legally shot by Texas homeowners during attempted break-ins. On top of that, they throw out four letter word after four letter word in the trauma bay and then go on to treat our nurses like another four letter word. It's annoying and disheartening. One easily loses their faith in people. And just when you think these jackasses make residency completely worthless, something amazing happens to reel you back in and convince you to keep going.

On August 10, I was on call. My chief resident and I were in the middle of a case when the trauma pager went off letting us know a Level 1 (the most serious kind of trauma requiring a response from the team within 15 minutes) was coming in the door. My chief looked up and told me to go down to the trauma while he went on with a grueling ventral hernia repair. I scrubbed out and ran downstairs to the ER.

EMS relays the story. This was a young male found down at the scene after a wreck. He had been t-boned on the driver's side and was unresponsive at the scene. EMS intubated him before bringing him to us. He never lost vital signs, but his blood pressure had been persistently low--an ominous sign in trauma. I ran through my ABCs, his endotracheal tube was in good position, confirmed in multiple ways. He had good breath sounds on both sides. His chest xray showed some significant bruising to both lungs and a fracture of his left collar bone. He had a large, deep, bloody scalp laceration on which we placed a gauze dressing. On FAST scan, he had a small amount of fluid around his spleen. He had a small pelvic fracture on xray too. After 2 liters of IV fluids and 2 units of blood, my attending decided if his next blood pressure wasn't more than 100, we were going to the OR. I watched as his belly grew, bloody urine filled his foley catheter tubing, and his reading came back...still in the 90s. More blood was hung on the IV pole and off to the OR we went for an ex lap.

When we got upstairs, my attending and I stopped in OR 8 to tell my chief we were now in OR 12 with the trauma. While putting on our shoe covers, he jokingly asked, "You wanna go scrub him out and finish that ventral hernia so he can come do this?" I laughed and said "Heck no. He can join us later."

Prepped and draped, my attending and I opened him up--a long midline incision from his chest bone down to his pubic bone. Once we got "in", at least four liters of blood poured out. We cleaned up the blood and in typical trauma fashion and packed all four quadrants. Then we went exploring. His spleen was shattered. Out that came. His left side had a large hematoma surrounding his kidney and retroperitoneum that was controlled with more packing. We looked in his pelvis. Thankfully, his pelvic fracture wasn't causing much bleeding. Then we looked at his liver. The capsule was torn in at least 7 places, he had a large hematoma on the left lobe, and two deeper lacerations towards his back. We used the argon laser to help control the bleeding. He continued to ooze so we packed the liver with laparotomy sponges. Still oozing. At this point, I noticed a hole in the left side of his diaphragm. He was somewhat stable at this point, so we repaired that. The bleeding seemed to be controlled for the time being. We placed a wound VAC and got out of the belly. My attending went to the head of the bed and repaired his scalp lac while I put chest tubes in on both sides. Stabilized, we sent him to the ICU. He received 27 units of blood and an additional 37 units of other blood products by the time he got there. And one whopping dose of factor VII. The best part is that anesthesia had done a fantastic job of helping to resuscitate him so he NEVER received one dose of a pressor.

And that's all in the first couple of hours. To be continued...

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