Back to Work I haven't blogged in a couple of weeks because I took a mini vacation and was off for 10 days. Thumper and I didn't have any specific plans and didn't "go away" on a trip. Sometimes that is the best kind of time off. We saw a few movies, spent a day at a big farmer's market/flea market and took a few bike rides. It was very relaxing. Now it is 05:30 in the morning of my first night back to work. I finished a case involving a 40 year old man who has been in a persistent vegatative state for two years after a bad head injury. It was a routine kind of case. The case that followed was anything but routine. Most of the time I love my job. Occasionally I do one that almost makes me wish I wasn't the nightshift trauma guy. About 1:00 in the morning they rushed up a 16 year old girl with 2 severe stab wounds. The first was a large slash wound that ran from her hairline, across her forehead, through her left eye and down through her cheek to her mouth. It was bleeding a lot but it was not the worst wound. The second wound was to the back of her neck. It was bleeding profusely and the surgeons could not be sure whether or not the her spine was involved. We started her case with her lying face down on the bed.It turned out that the spinal cord had been almost completely severed. At the level that the cord was damaged this young lady will be permanently paralyzed from the neck down and will need a ventilator to breath. The surgeons stopped the bleeding but there was nothing they could do for the spinal cord. I gave her 16 units of blood products to replace what she had lost. We turned her over and they worked on her face. They closed the wound but her eye was to severely damaged to save. I left the breathing tube in at the end of the case and we took her to the ICU. I cannot imagine what it will be like for this 16 year old girl when she wakes up and realizes what has happened to her. The truely horrible part is that we heard that she had been stabbed by her brother. Sometimes I hate this place.

Very Busy Night First an update. The 22 year old with the gunshot wound to his aorta is still alive and slowly recovering. It is now a week since he was shot and he is still in the ICU and still has a breathing tube in. He has been back to the operating room several times and will be back several more times before they can finally completely close his abdomen. Now to last night. When my student and I arrived things looked it might be a semi quiet night. There were two cases that were just finishing up and we set up to do a laproscopic appendectomy on a 23 year old women. She was obese which can make getting the breathing tube in a little more difficult but otherwise she was healthy. My student handled her case with ease as I sat back and watched him. About 20 minutes before the case was done we got word that a gunshot wound victim was being brought to the operating room. Normally if I am already doing a case the on duty anesthesiologist and his resident will start the next case until I can take it over. I sent my student to help start the case as trauma is why the Army sent him to work with me in the first place. I finished the appendectomy, woke her up, and took her to the recovery room. Then I headed into the trauma. The patient was a 13 year old girl with a single gunshot wound to the lower pelvis. We heard later that she had been at a party or family gathering. Someone else showed up and started shooting. Eight people were shot. Five of those people were brought to my hospital and two ended up coming to the operating room. By the time I got to the operating room my student had placed the breathing tube and the case was underway. The bullet had hit her bladder as well as her vagina. The wound to her vagina was not serious except for the fact that it was bleeding a lot. The surgeons closed that wound first to stop the bleeding and make it easier for them to see the bladder to repair it. We ended up giving her two units of blood to replace what she had lost. The bladder injury was easily repaired but could be a life changing one. the injury was to the neck of the bladder. This is the area that controls bladder function. The surgeons could not be sure whether or not it would function properly afterward. Only time will tell whether or not she will be incontinent for the rest of her life. While we were finishing the 13 year old case the second gunshot wound was brought up and done by the anesthesiologist and his resident. I heard that the young man had bleeding into his right lung that was quickly stopped by the surgeons who then placed a chest tube. Our next case involved a 62 year old man who had been in the hospital for several weeks after a fall from a ladder with a head injury. He was still in critical condition. He had been placed on a medication called Levophed several days before. Levophed is a powerful IV vasoconstrictor used to increase a patient's low blood pressure when nothing else will. In some cases it will cause the tips of a patients fingers or toes to turn black because the vasoconstriction is so tight that blood doesn't flow to the tips. With out the levophed the patient probably would have died several days ago. In his case he had lost circulation to part of his intestines which had to be removed by the surgeons. We got him back to the ICU after the surgery but he has a very low chance of surviving. Our last case of the night involved a 23 year old man with a torsioned testicle. One of his testicles, for often unknown reasons had twisted within his scrotum cutting off the supply of blood to itself. This condition is extremely painful and must be surgically corrected within a few hours or the patient will loose the testicle. We put the patient to sleep and then was replaced by the day shift. Overall a very busy night.

Walked into a Trauma Last night I walked into work to find out they had just taken a man with a gunshot wound to the operating room. I quickly changed into scrubs and went to the operating room. My student, eager to do any trauma case that rolls through the door, was already in the room. It turns out that we needed all the help we could get. The patient was 22 years old and had multiple gunshot wounds to the abdomen. One of the bullets had hit his lower aorta which is the largest artery in the body. The patient had severe bleeding. The surgeons placed a clamp on the aorta above the damage and worked to repair it. We gave the patient large amounts of blood and other fluids. About 5 hours later the surgeons had repaired the aorta and did a "temporary" closure of his abdomen planning to bring him back to the operating room later for further work. The EBL, which stands for estimated blood loss, was at least 13 liters. We had given over 50 units of blood products and lots of other fluids. In cases where massive transfusions are given there are many possible complications. One that occurs frequently is that the patient's blood doesn't clot the way it normally would. This can cause further bleeding. Another complication is overall swelling from all the fluids that are given during a resuscitation. Our patient was taken to the ICU where more blood products and fluids were given. Several hours later he was brought back to the operating room. He was still bleeding internally and the surgeons needed to look for the source. My student and I were replaced by the day shift before the end of the second surgery. I will check on the patient when I go into work tonight.

Busy Night Last night was the last of three nights at work and it was a busy one. My student and I started the night with an appendectomy. Usually a routine case this one was complicated by the fact that the 31 year old women was diagnosed with tuberculosis 2 weeks ago. This meant that all of us in the operating room had to wear special protective masks. These masks cover your mouth and nose, and are very tight and uncomfortable. Her case went well and she was placed in an isolation room after her surgery. The second case of the night involved an 18 year old woman who was in a car accident. Her case was complicated by the fact that she was 8 weeks pregnant. She had a lot of internal bleeding when the surgeons first opened her up. They discovered that a mesenteric artery which is an artery to the small intestines was the source of the bleeding. Once the bleeding was stopped the surgeons repaired some other damage to her intestines. They inspected her uterus and found no damage. She had lost a lot of blood which we replaced in the operating room but only time will tell as to whether or not her baby will have problems. The last case of the night involved a 20something year old man with a gunshot wound. The bullet went through his left upper leg breaking his femur and then it hit his right leg severing the artery. He had suffered severe bleeding before getting to the hospital and was given 7 units of blood in the emergency room before being rushed up to the operating room. The surgeons quickly started working on his right leg to restore the circulation without which he would loose his leg. My student and I gave him 6 more units of blood and other fluids during the case. The surgeons were able to repair the artery and felt he had a very good chance of keeping his leg. We were replaced by the day shift as the ortho surgeons were preparing to fix his broken left femur. All in all a very good night for my student but I am glad to have the next few nights off.

Good First Night Last night was my first night with another Army student. As his predecessor he will be working with me for four weeks. Last night started out very quietly and stayed that way until about 4:45 in the morning when we got the word that they were bringing up a man with a stab wound to the heart. He was 45 years old and was awake and remarkably calm for a man with a stab wound in his chest about an inch above his left nipple. As soon as we had him asleep with a breathing tube in place the surgeons went to work. Their incision ran from just above his sternum to his navel. They split his sternum with a special saw and opened his chest like a clam shell. His pericardium which is the sack around his heart was full of blood that was causing his heart to pump blood less efficiently. His blood pressure was only about 65/30. They cut open the pericardium and released the pressure around the heart. His blood pressure went up to 110/60 almost immediately. They found a small hole in his pulmonary artery right where it leaves the heart. This is the big artery that takes the blood from the right side of the heart to his lungs. The surgeons repaired the hole and found no other damage to the heart. The man lost about a liter of blood which we replaced with 8 units of blood and other fluids. He should fully recover. My student and I were relieved by the day shift just as the surgeons were starting to close his chest. Not a bad case for my students very first trauma.