Shotguns and Drunk Drivers This is the last weekend my current student will spend working with me. It has been a good rotation for him with a number of trauma cases. This weekend so far he has seen the extremes of the night shift. Friday night was quiet. We did not do a single case. I spent the night watching DVD's and he spent it studying for the certification exam he will be taking for graduation in November. Last night was different. It started quiet but from about midnight on we got extremely busy. Our first case was on a 36 year old man who is severely mentally challenged. Mentally he is the equivalent to about a 1 year old child. He had a history of seizures. He had a shunt that had been placed in the past that drained excess fluid in his brain into his abdomen. Unfortunately the shunt was badly infected and needed to be removed. The patient was septic with a low blood pressure and a temperature of 104 degrees. His case went smoothly and with antibiotics his infection should be eliminated. The second case of the night involved a 19 year old man who had been shot in the abdomen at close rang with a shotgun. He had almost no blood pressure on arrival to the operating room. We started giving him blood products as fast as we could and the surgeons went to work. His spleen was quickly removed as well as his left kidney which was shredded. He had multiple holes in both his small and large intestine as well as holes in his abdominal aorta. We gave over 16 units of blood products very quickly and the surgeons worked as fast as they could but unfortunately we were not able to save this young man. The damage done by the shotgun blast was just too severe. Our next case involved a 19 year old girl who was involved in a multiple car accident. We heard that the car she was in was hit head on by a drunk driver going the wrong way on the freeway. Even though she had her seat belt on she still had significant injuries. The surgeons removed her spleen as well as several damaged segments of small intestine. We gave her 6 units of blood and left the breathing tube in at the end of the case. She will probably require at least one more surgery in the next day or two. While my student and I were doing that case the drunk driver was being worked on in another room. His injuries were very bad including damage to his liver, spleen, intestines and spinal cord. He did not survive. Hopefully tonight will be less busy.

I Wish a Student Had Been There. Saturday night at work turned out to be very eventful. It would have been a great night to have had a student working with me. About midnight we got word of an 18 year old with multiple stab wounds that was being brought to the operating room. The surgeons planned to place chest tubes on both sides and then to look inside his abdomen using a laprascope. They do this to see if there is any internal damage. It is easier on the patient to recover from several small scope holes. If they see damage with the scope they can then do the big incision down the front of the abdomen and repair the damage. The patient was awake when he arrived but he was obviously intoxicated and semi incoherent. I put the patient to sleep and the surgeons started to work. Initially they saw no evidence of internal damage to the stomach and intestines. Within a short time I started seeing irregularities in the patient's heart rhythm. He started having premature atrial contractions (PAC's). This irregularity is not uncommon and by itself is not life threatening. To see it in an 18 year old boy however is uncommon. It could mean that the boy had a congenital heart problem or that his heart had been injured when he was stabbed. Another likely cause in this situation is that the boy had been taking drugs. There are a number of illegal drugs that can cause irregular heart beats. Cocaine and methamphetamine are especially known for cardiac affects. I told the surgeons about the irregular heart beats and they decided to do a pericardial window. This is where they make a small hole in the pericardiam which is the sack of tissue surrounding the heart. This would allow them to see if the heart had been injured and was bleeding. Using the scope they looked at the pericardiam and started to make a small incision. As soon as they started the patient's heart rhythm changed to one called ventricular fibrillation. This is a deadly rhythm where instead of beating in a coordinated way the heart just quivers and shakes like a bowl of jello. This is the situation you see on TV where the doctors use the paddles to shock the victim to restore a proper heart beat. The patient's heart was not pumping any blood and he would die unless we could restore a normal heart beat. The surgeons took a scalpel and quickly opened the boys chest. One of them started squeezing his heart with his hands to make it pump blood while at the same time the internal paddles were opened and prepared. With the internal paddles we were able to directly shock the heart. With just one shock his heart beat returned to normal. I gave the patient medications to help the heart beat stay normal. The surgeons were able to then finish the case. I left the breathing tube in at the end of the case and we took him to the ICU. Tonight I went over to see how he was doing. He still has the breathing tube in but he has been awake and following commands so hopefully there was no brain damage. His heart beat has stayed normal and it looks like he will recover. I talked to the nurse taking care of him and she informed me that he had tested positive for methamphetamine. My second case of the night was also challenging. The patient was a 45 year old man with a strangulated hernia. This is where a loop of intestine gets twisted in a hernia. If it is not treated quickly the piece of intestine can die and will then have to be removed. This case was complicated by the fact that the patient was 5 foot 9 inches tall and weighed 300 pounds. He informed us that when he had his gall bladder removed 8 years ago he was told "they had a hard time putting the breathing tube in for my surgery." He had no further information and we did not have any records from the previous surgery to see what had been done then. Normally when I do a general anesthetic on a person I give them medicine in their IV that makes them completely unconscious then I place the breathing tube in their throat. In this case I could not be sure that the breathing tube could be placed in the normal way. If I put the patient to sleep and could not get the tube in it is possible that he would not be able to breath and would then die. It was decided that we would do an Awake fiberoptic intubation. This means the patient would be sedated but semi awake as we placed the breathing tube in place. Several injections to his throat and medicine sprayed into his mouth numbs his throat eliminating the gag reflex. The beauty of this technique is that the patient continues to breath on their own for the whole procedure. It took several minutes but I was able to place the breathing tube through his nose into his lungs. I was relieved by the day shift before the case was completed. It really is a shame that I did not have a student with me

As Promised I promised mom in my last post that I would write about any interesting cases that I do this weekend. Thursday night turned out to be a very busy night. First a little background information. Last Sunday (13 Sep) My student and I did a case involving a 45 year old woman who was kayaking on a river after dark. She and her kayak were struck by a fast moving motorboat and she was severely injured. Her spleen was ruptured, her liver had several large heavily bleeding lacerations, she had multiple broken ribs with a collapsed lung and other injuries. She had been in cold water and her body temperature was only about 89 degrees at the start of the case. This made things much more difficult because the low temperature interferes with proper blood clotting and can cause her heart to beat irregularly. We raised the room temperature to 90 degrees and used fluid warmers to try and raise her temperature. The surgeons removed her spleen, placed chest tubes to re expand her lung and attempted to stop the bleeding in her liver. After several hours of work her body temperature was up to about 95. She had received over 70 units of various blood products but was still bleeding. The surgeons ended up packing sponges around her liver and temporarily closing her abdomen. we took her to the ICU where she would receive more blood products in hopes that her blood would start clotting normally again. Having seen other cases like this one in the past I told my student that I thought she had only a very small chance of surviving the next 24 hours but since it was our last night on duty we might not ever know how she did. It turns out she survived for 5 days. She had several other surgeries including brain surgery for bleeding in her brain. Late Thursday night she was rushed to the operating room again. Her right lung, the one that had been damaged by broken ribs, had suddenly started to bleed again very badly. The surgeons did everything they could and I gave her more blood products but this time we were unable to save her. I think that the severity of her initial wounds compounded by the complications caused by the low body temperature were simply to much for her body to overcome. Honestly I was truly surprised that she had survived more than 24 hours.

Because Mom Told Me To. Yesterday Thumper and I went up for a visit with my mom. We had a great lunch at Olive Garden and then spent some time at her house. She was having a small problem with her computer that Thumper was able to help her with. Then she asked me why I had not updated my blog in about 3 weeks. I had no excuse other than blog laziness. Their have actually been a few good cases that I and my current student have done the last 2 weekends I just never got around to actually writing them down in the blog. So Mom, this blog entry is for you and I promise that if I do any interesting cases during the next 4 nights I will write about them too. Please don't send me to bed without supper!