“Better lucky than good”
I will never forget my first day of intern year. My first rotation was hepatobiliary surgery plus I was on general surgery trauma call.
I arrived at the hospital at 530am, then spent the morning rounding on 25 sick hepatobiliary surgery patients while answering pages about newly admitted trauma patients from the night before. I somehow managed to write 25 notes as my pagers continued ringing for the next 16 hours. At 8pm I was in the middle of breakfast when the trauma pager went off. I rushed to the emergency department.
By the time I got there the senior surgical resident had already intubated the patient and my attending was examining the abdomen. He looked up, turned to the senior surgical resident and said: “let’s go to the OR”. I learned later the patient was a young woman with several gunshot wounds to her abdomen. She needed emergent surgery to explore her abdomen then repair the damage. After my attending and senior resident went to the operating room I answered the 10 pages that accumulated over the last 45 minutes. When my pages were finally taken care of, and I ate lunch at 11pm, the trauma pager went off yet again.
Before my senior resident and attending could arrive my junior resident and I met at the trauma bay. Suddenly 6 people burst though the glass receiving doors leaving a trail of blood behind them. The patient was ghost white. Blood was slowly oozing out of 4 stab wounds in her abdomen. Tonight was not a good night to be an abdomen. I looked with wide eyes at my junior resident- I really hoped she knew what to do! With a slight tremor in her voice she asked for the thoracotomy tray.
A thoracotomy is an incision between the ribs to access the chest cavity in order to perform surgery on the heart and lungs. In the context of a trauma it is used to clamp the aorta to prevent catastrophic bleeding , especially if a large abdominal branch of the aorta is injured. The aorta is clamped just distal to the take-off of the carotid and brachiocephalic arteries, the large blood vessels that supply oxygenated blood to the head and arms. When done correctly all blood is shunted to the arms and brain, buying time to repair the damage to the blood vessel and before the patient loses all of their blood volume or sustains irreversible brain damage.
I saw a few emergency room thoracotomies in medical school in Detroit- they are brutal, bloody, and have a 99% failure rate. Most of the time patients already have irreversible hypoxic brain injury by they get to the emergency department. My junior resident decided to do a thoracotomy because someone witnessed the stabbing and called 911 immediately; EMS, who happened to be nearby, arrived within 10 minutes, performed high quality CPR, then brought her immediately to the emergency department. If there was anyone who could benefit from an ER thoracotomy it was this patient.
The junior resident and I donned sterile gloves. She made an incision between two ribs, retracted so she could visualize the left thorax, then bluntly dissected until she visualized the heart and aorta. Then she clamped the aorta! Now all blood flow would be redirected ONLY to the head and upper extremities. Furthermore the patient could no longer bleed from her wounds because there was no blood going to her abdomen or legs. I carefully inserted my hand into our patient’s chest and manually pumped her heart as nurses gave blood products. She wasn’t conscious, but she did have a blood pressure. And my hand was pumping blood to her brain. Hopefully we could get to the OR in time.
After what seemed like an eternity our attending arrived from the operating room- he asked for a scalpel and made a large midline incision in the emergency department! He pulled out the patient’s bowel, examining it for any injury. Then he looked at the major arteries and veins of the abdomen. He carefully returned her bowel to her abdomen, taped gauze over the incision, and helped transport her to another operating room, which apparently was ready. My junior resident and I locked eyes. I knew this was a once in a lifetime case for her. I also knew I had no idea what I was doing in the operating room. Without her asking I offered to take her pager so she could scrub in. Now I was holding 5 pagers and 2 phones!
For the rest of the night I managed half of all the surgical patients in the hospital and saw 5 more consults. Luckily nothing was serious enough to warrant the operating room. I wrote all the notes, ate dinner at 430am, then met my attending and junior resident in the surgical ICU at 5am. I presented my consults with their history of present illness, medical history, and plan. Then I met my fellow intern at 0530, signed out my patients and stumbled home. As I collapsed on the couch, my last thought before falling asleep was: “what in the world did I sign up for?!?!”.
The patient walked out of the hospital 2 months later.