What We Do

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What We Do

 

It’s a rainy Saturday night, a welcome rarity in the Phoenix Valley. It’s not the hard rain of the August monsoons, but a light, steady winter rain. The Emergency Room has been fairly quiet and the trauma service has had no calls since change of shift twelve hours earlier. That is about to change.

The pagers don’t all go off at once, but rather in a rolling wave from the trauma nurse to the lab tech to the x-ray tech and finally to the trauma surgeon. The small green screens all deliver the same message:

“Level one by ground, ETA 10 min, RED

“GSW to chest and abdomen, no vitals given”

The team gathers in ER bay 53, one of four trauma bays, all prestocked with equipment and supplies above and beyond the normal emergency room requirements. There are sterile instrument packs for central line insertion, chest tube trays, suture trays and an emergency thoracotomy pack. There are rapid infusers – IV pumps that can push fluids at rates of 250cc to 400cc per minute; pneumatic tourniquets; a cast cart with webbing and plaster; and the usual stock of sterile gloves, gauze, and suture.

The conversation is light, that of people who have worked together many times before, greeting one another and bantering. A dark haired woman enters and moves to the head of the ER gurney that occupies the center of the bay. She is young, of medium height and build; attractive in spite of the almost shapeless surgical scrubs she wears and the lack of make-up. She would look nice in a short summer dress on the patio of a Scottsdale nightspot or strolling in La Condesa in Mexico City.

A few minutes later the ER clerk announces over the intercom, “Trauma is here in 53”, and the light banter ceases. Eyes swing to the paramedics moving quickly but purposefully into the bay.

For the first time the dark haired woman speaks, “Go ahead with report,” she says with a light Mexican Spanish accent.

One of the paramedics speaks out, “28 year old male shot twice, once in the left chest, entry just below the nipple, exit posterior near the tenth rib. Second wound enters in the left flank, exits in the right upper quadrant. Pressure has been low, in the 70’s systolic; pulse 130. No breath sounds on the left. We started two IV’s, 18 gauges in the right forearm and in the left antecubital. He’s gotten 900cc of saline en route and 100 mikes of fentanyl.”

“Thank you,” says the dark haired woman, already pressing a stethoscope to the man’s chest as a nurse wields surgical shears, cutting away his bloody clothing. Other techs move in attaching oximetry and EKG monitors, checking the integrity of the IV lines and removing his shoes and pants.

“I want to set up for a chest tube on the left and we’ll need the O negative emergency blood,” says the woman, clearly taking charge of the team. She glances at the monitors. “Better call the blood bank and start the massive transfusion protocol and tell the OR to set up for a laparotomy.”

Rapidly but clearly she calls out the list of his wounds, his breath sounds, his other physical findings. She asks him if he has other medical issues; if he takes medications; if he has any drug allergies; all the while doing a quick head to toe exam.

She pulls on sterile gloves and sets out the instruments she will need to insert a drainage tube into the left side of the man’s chest in order to drain blood and reinflate his collapsed lung.

A technician asks, “What size tube, Dr. C?”

The trauma surgeon, for that is who the dark haired woman with the slight Mexican accent is, answers, “34 French,” without looking up from her work. She trusts the technician to get the right tube and have it ready by the time she has made a small incision in the patient’s skin and probed through the muscle into the chest cavity. She inserts the tube and a rush of air and blood flows through it into a collection device. She secures the tube with a few quick sutures.

“Alright people, lets package him and move.”

By this time, the rapid infusers have pumped almost 500cc of red blood cells, an equal volume of plasma, and a liter of saline into the man’s veins. His blood pressure is better, although still low, and his heart rate has slowed, signs that the fluids have helped replace some of what he has lost.

The side rails of the gurney are raised and it starts to move, pushed by the trauma nurse who watches the electronic readout of his pulse and blood pressure on the small screen mounted by his feet. Techs follow closely, pushing the IV poles and keeping the lines from becoming tangled.

Eighteen minutes after arrival, he reaches the operating room, a bit better than average but not a record. Twenty-three minutes after arrival and five after reaching the OR he has been anesthetized, scrubbed, and draped and the surgeon makes her first incision.

Two hours and forty-seven minutes later the incision is closed and the patient is being moved from the OR table to an ICU bed. He will remain intubated and on a ventilator for the rest of the night. The bullet tore off a piece of his left kidney, lacerated his pancreas, shredded his splenic artery and punched through his stomach and liver before exiting the front of his abdomen.

In a single operation, the trauma surgeon over sewed the bleeding upper pole of the patient’s kidney, took out his spleen, removed the tail of his pancreas, removed a short segment of small intestine and put the ends back together, closed two holes in his stomach and cauterized bleeding areas in his liver. She placed drains in the area and closed her incision.

She follows the gurney to the elevator for the short ride up one floor to the surgical intensive care unit. She gives orders for his ventilator settings, his IV fluids, antibiotics, and mundane things such as dressing and drain care. Over the next twelve hours she will monitor his oxygen levels and vital signs, adjust fluids and ventilator settings, check on his urine output and review his morning x-rays.

Three days later, he is leaking bile from one of his drains, a potential sign of an intestinal leak. She takes him back to surgery and explores the abdomen. The bile is leaking from the liver wound. The intestine is intact and the bile leak is fixed with a single stitch.

His recovery is slow – his lung doesn’t seal right away, his intestine shuts down for almost a week before opening up, he leaks pancreatic fluid from his drain – but he survives and goes home twenty days after being shot.

This is a summary of an actual case handled by one of my colleagues. It is unusual only because penetrating trauma is unusual in my trauma center, accounting for just twelve percent of all admissions. What is common to all of the injuries we handle is the team approach with the trauma surgeon as the team leader. Also key is the ability of that surgeon to handle a wide variety of surgical problems across multiple specialties – in this case, a kidney repair, a splenectomy, a partial pancreatectomy, repair of stomach and intestine, repair of the liver, ventilator management, critical care management, antibiotic selection, wound management and discharge planning.

Trauma surgery mixes general surgery at its best with critical care medicine. It requires a good grounding in orthopedics, neurosurgery, plastic surgery, chest and vascular surgery, and emergency medicine. Even if you aren’t going to be the one actually operating on a complex fracture or a brain hemorrhage, you need to know what you are looking at and understand the principals of managing those problems so that you can communicate effectively with the consultants you call. You never know what’s going to come through the ER door on any given day.

 

 

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