No Such Thing as a Routine Case Thursday night at work I was asked to finish off a case that had already been going for about 7 hours. My student and I took over the case which was finished in about an hour. By the time we took over the case it was pretty much over and I would not normally blog about it. In this case the story is so sad, so scary that I felt I had to talk about it. On Thursday afternoon at a different hospital a 20 year old otherwise healthy man went in to an operating room to have his gallbladder removed. The case was going to be done laproscopically which is how most gallbladders are routinely removed. To do the case several laprascopic ports have to be put into place first. The ports are hollow tubes that are a little bigger around than a pencil. Once they are in place the surgeons can insert long thin instruments and a camera to see inside and do the work to remove the gallbladder. The ports themselves have to be carefully put in place. A very sharp tip is put through the port which is then inserted through the abdominal wall. Imagine a pencil with razor sharp tip being pushed through the abdominal wall. Great care must be used to be sure that the port gets through the abdominal wall but does not damage anything on the inside. Over the years I have seen several cases where internal damage was accidentally done by the surgeon as he/she was placing the ports. The damage has always been to the intestines, serious but usually not life threatening. Unfortunately the damage done in this case was much more serious. Somehow the surgeon at the other hospital hit the patients aorta while placing the laprascopic port. This caused massive bleeding as the aorta is the largest artery in the body. They opened the patients abdomen and got a clamp on the aorta to stop the bleeding saving the patients life. Unfortunately there was not a vascular surgeon at the other hospital who could repair the damage to the aorta. With the aorta clamped there was no blood flow going to anything in the lower half of the patients body. The patient was kept asleep, was packed up and was transported to the hospital where I work. By the time he arrived and our vascular surgeon was able to rush him to our operating room the aorta had already been clamped for several hours. Our vascular surgeon worked for hours on the patient. He repaired the damage to the aorta and then worked on the arteries and veins in his legs to remove blood clots that had formed during the hours the aorta was clamped. Unfortunately when my student and I took over the case late Thursday night the surgeons were completing the amputation at the knee of his right leg. We left him intubated and took him to the ICU. When I went in to work last night I got an update on the patients condition. That afternoon they returned him to the operating room to amputate the left leg just below the knee. His kidneys have been damaged though how badly is yet to be determined. He may end up impotent and unable to produce viable sperm so he may not be able to father any children. Finally he will still need to go back to the operating room in the near future to have his gallbladder removed. So much for a "routine" surgery.

Oh My God Trauma This is my current students third of four weekends working with me. We have done several good traumas already including stab wounds and gunshot wounds. Trauma cases range in severity. Some are not any more difficult than a routine case. Others are somewhat more hectic and involve us giving a few units of blood products. Occasionally we get what I like to call an "Oh My God!" trauma. This is a trauma where the patient is severely injured and loosing massive amounts of blood. They can sometimes literally be minutes from dying if something isn't immediately done. Tonight my student experienced his first "Oh My God!" trauma. The patient was a 19 year old girl who had been in a "roll over" motor vehicle accident. She was rushed up to the operating room with very little notice. A breathing tube was already in place and she had already received several units of blood by the time she was brought up. Her abdomen was enlarged and tight a sign of massive internal bleeding. Her blood pressure was low and her heart beat was very fast in the 140's. This is caused by the blood volume being low. It turned out that her spleen was ruptured and had to be removed. Her liver also had a significant laceration. Both the spleen and the liver were bleeding badly. Over the next hour we pushed in over 25 units of blood products and her vital signs stabilized. The surgeons removed her spleen and stopped the bleeding in her liver. We left the breathing tube in and took her to the ICU. The surgeons will have to operate on her at least one more time but hopefully she will recover. We have two more nights to go.

New Student I have a new student that I am working with. This is his second of 4 weekends that we will work together. Last weekend was extremely quiet. We only did 3 cases and none of them were trauma related. Last night my student got his "trauma cherry" busted. A 30 something year old women was brought up from the emergency room. She had a self inflicted gunshot wound to her left forearm. We were told that she had tried to commit suicide by shooting herself. The bullet left an entrance wound about the size of a nickle on the inside of her forearm. Unfortunately the bullet hit the ulna, one of the two bones in the forearm. The ulna had shattered and she had an exit wound as big as my fist on the backside of the forearm. No major blood vessels were hit but there was possible nerve damage. A large section of the muscle was also gone on the outside surface. She will need skin grafts to eventually close the wound and will have greatly diminished use of her left hand and wrist. It was a good first trauma case for my student and he still has 13 more nights to go over the next 3 weeks.

Back to Work I took a little time off and I guess I didn't get around to posting anything. Thumper and I went into San Francisco a few days with our son. We had a great time playing tourist. Saw a few movies, including Star Trek on the giant IMAX screen, and otherwise just relaxed. This weekend however I was back to working the night shift and it was a very busy weekend. Thursday night I was working by myself and did three "bread and butter" cases. These included two different young women with ectopic pregnancies and an older man with a urological problem. All three were easy cases and the patients all did well. Starting on Friday night and for the rest of the weekend I had a student working with me. Like my former students his main goal working with me is to get some experience doing trauma cases. This weekend he got to do some really good trauma cases. Over the weekend we did three different brain surgeries. Two involved patients who had been in car wrecks and the third patient had fallen. We did two cases involving patients with stab wounds. A 40 something year old man had been stabbed in the leg just above the knee. It was bleeding profusely when he arrived from the Emergency room but the bleeding was quickly under control. The second stabbing case involved a 20 something year old man with multiple stab wounds to the chest, arms and abdomen. We found out after we put him to sleep that only two of his stab wounds were new. The other three he had received and been treated for two days before. Sunday night turned out to be the busiest. Minutes after our shift started a man with about 10 gunshot wounds to the chest, abdomen and legs was rushed up from the Emergency room. He had lost a lot of blood already as we started working on him. We worked on him for seven hours to save his life. The surgeons put in chest tubes, repaired damage to his intestines and his bladder. They stopped bleeding from three major blood vessels in his legs. His left leg was broken in two places. My student and I gave him about 45 units of blood products as well as 18,000cc of other fluids. We left the breathing tube in place at the end of the case and took him to the ICU. The surgeons felt he had a 50/50 chance of surviving and he will require several more surgeries. After a quick lunch break my student and I took over and finished a case involving a police officer who had been shot in the arm. The surgeons had to repair both major arteries and repair a broken bone. They felt that the officer would fully recover but would probably be months in rehab to get full use of his arm back. This student will be working with me for two more weekends but he has already had a great start on trauma.

AAA Most people who see AAA think about the company that will help you with roadside assistance when your car breaks down. In the operating room AAA stands for Abdominal Aortic aneurysm. The aorta is the largest artery in the body. It leaves the heart and travels down next to the spine until is splits in two with half going to each leg. Many other arteries branch off of it to supply the entire body with blood. An aneurysm is where an artery has a weak spot in the wall and it balloons out. A ruptured AAA is a life threatening emergency. With a hole in the largest blood vessel in your body you can bleed to death in minutes. The usual procedure in the operating room for a ruptured AAA is one where everything happens very fast. I put the patient to sleep and start pushing blood while the surgeon quickly opens the abdomen and gets a clamp on the aorta to stop the massive bleeding. The problem is that the aorta is located in the back of the abdominal cavity and can be hard to get to. In some cases the patient can bleed to death before the surgeon can get the clamp on. Last night we got the word that a 56 year old man with a ruptured AAA was going to arrive in the operating room in about 10 minutes. As we always have an operating room setup for trauma the only thing I had to do to be ready was send to the blood bank for 10 units of blood to start the case. When the patient arrived he was in a lot of pain but was still conscious and able to talk which is a good sign. He had bled into his abdomen which was distended but there is only so much room in the abdominal cavity and the internal bleeding must have slowed. It is when the surgeon opens the abdomen that the serious bleeding begins again. I was ready to quickly put the patient to sleep and start giving blood when the surgeon told us he was going to do something a little different than I am used to. He asked me not to put the patient to sleep immediately. Instead he placed a large IV line into the patients left groin. Through that IV line he threaded a balloon up into the aorta above the point where it was ruptured. Once the balloon was in place and inflated I put the patient to sleep and the surgeon opened the abdomen. With the inflated balloon preventing further bleeding the surgeon was able to get down to the aorta and clamp it easily. The case proceeded well and we finished about 5 hours later. I gave the patient a total of 7 units of blood products when I had been expecting to give about 25 units. The surgeon showed me the balloon he had used after the end of the case. Inflated it was the size and shape of a small egg on the end of a long tube. That little balloon helped save my patients life.

Back to Work My ankle is healing but it is still sore but I can walk on it. So I was back at work this weekend and I did several strange cases. Thursday night I did three routine cases on healthy people. Two of them had their appendices removed and the third young man had a torsion testicle. A torsion testicle means the testicle gets twisted in the scrotum. It is extremely painful and if not corrected within about 6 hours the testicle will die and have to be removed. The surgeon felt that this mans testicle would be all right. Friday night I did two cases. A 56 year old man with a chronic back injury had sudden onset of loss of sensation and movement in his legs. The surgeons operated on his spine to relieve pressure on his spinal cord. It will be several days before they will know if he has permanent damage to his spinal cord. The second case of the night involved a 26 year old with a single gunshot to the outer edge of his abdomen. He was very stable and it turned out that the bullet had not caused any internal damage. Saturday I did a case of a young man with a stab wound to the abdomen right near his belly button. He had minor damage to his small intestine which the surgeons easily repaired. Later that night we took out a man's gallbladder. Sunday night I did two strange cases. The first involved a 28 year old women who had been kicked by a horse in the abdomen. Her spleen was ruptured and had to be removed. she had lost about 1500 milliliters of blood. I gave her nine units of blood products. She also had a broken rib which had made a hole in her diaphragm which the surgeons repaired. The final case of the night involved a 30 year old man with a fish hook in his eye. Fortunately it in the white side part of the eye and the surgeons did not think his vision would be effected. That's what I did over the last weekend.

Sometimes Things Suck The master bedroom of our new house faces the afternoon sun and the room gets hot. We bought a really nice roll down shade for outside to block the sun from beating down on the window. I was putting it up today when things went badly. I had placed the ladder in a flower bed so I could drill holes to mount the hanging bracket. I was on the ladder's third step when it shifted and I fell to the sidewalk below. The good news is my left wrist, elbow and ankle are not broken. The bad news is they are sprained, my ankle is badly sprained. So now my wrist is in a brace, my arm is in a sling and my ankle is wrapped and has a frozen bag of peas on it. The Vicodin helps some but I suspect I am going to hurt more tomorrow. Instead of working this weekend I will have my butt planted in front of the TV with my ankle iced and elevated. By the way one handed typing sucks too!