Sunday, June 28, 2015

Fourth of July


I was  a newly minted second year resident and it was my second night taking call at the county hospital.
I am ready for anything, I thought.
“Call ER, Dr. Gelber”
It was 9:15 am.
“We’ve got a fifty year old male with a stab wound to the abdomen,” the ER attending reported.
And so it started.
I made my way down there and found Jose. He was stable and there was a two cm wound just above his umbilicus.
In those days we usually locally explored the wound and if it penetrated the peritoneum the patient was explored.
I called for some local anesthetic, an instrument tray and some retractors. Just as I had learned as an intern, I extended the stab wound and followed it down, down, down, deeper into the abdominal wall. Through fat, then fascia, then muscle, then more fascia I explored. After five minutes I found peritoneum and the stab wound kept going.
Looks like he’s going to the OR.
We, that is myself and my interns, got him typed and crossed, started antibiotics and called my Chief, a fourth year resident.
“I’ve got Jose here with a stab wound to the abdomen, penetrates the peritoneum. I think he needs to go to surgery. He’s stable and he should be ready whenever you are.”
Twenty minutes later, off he went.
Maybe I can finish some of the work I need to do. Write some progress notes, check some X-Rays.
ER again?
“Twenty nine year old male with a gunshot to the chest and abdomen just rolled through the door.”
“I’m on my way,” I answered. I then started my fast walk back down to the ER. Sometime during medical school I decided that there are very few emergencies that require me to run. If the patient is so sick that I have to be there ten seconds sooner, then he probably wasn’t going to survive, no matter what I did. But, I can walk pretty fast.
Miguel was rolling into room 4 as I arrived. He was awake with a BP of 90/50, heart rate of 110.
“Do you have any medical problems?” I asked, “Any allergies to medicine? Do you take any medicine regularly? Any surgery for anything in the past?” Can you tell me what happened?”
“I was sittin’ on my porch reading the good Book when these two dudes came up and shot me,” he explained. “Bam. I wasn’t doin’ nuthin.”
“What about any other medical history?” I asked again.
“No, I never go to the doctor, ain’t never been sick, don’t take no meds or drugs. Don’t drink o’ smoke,” he answered.
“Ok,” I sighed. “let’s get another IV going, and get him a gram of Mefoxin.”
I gave him the once over. He had one wound in his right chest which exited his right lower back and a second wound in his lower abdomen which went straight through. Tattoo’s extolling the virtue of his mother and his love for Angie adorned his chest and back. A large scar ran from his left shoulder to his mid forearm.
“What’s this scar from?” I wondered out loud.
“Cut myself shavin’,” he answered and then he smiled.
“Type and Cross for four units PRBC’s. Let’s get a single shot IVP to make sure he’s got kidneys and I’ll need a chest tube tray and he’ll need a Chest X-Ray,” I barked out, hoping either the nurse or my intern was paying attention.
I called up my Chief again.
“Gunshot wound to the chest and abdomen for you,” I reported. “I’m about to put in a chest tube and then we’ll take the picture for the IVP. He’ll be headed your way in about thirty minutes or so.”
And so it went.
Andrew came in with a stab wound to the right chest, the result of him losing an argument over a girl.
He earned a right chest tube and entered the queue to go to surgery.
Next came Miriam, complaining of severe abdominal pain. She said it started after she had rough sex with her boyfriend.
“How rough,” I asked as politely as I could.
“Well, I was laying on the bed like this…” And she spread her arms and legs.
“…and Billie, that’s my boyfriend’s name, was at the foot of the bed and he jumped on top of me. I got the wind knocked out and then my belly started hurting really bad.”
“Did Billie come with you?”
“I’m right over here, doc,” a voice called from the doorway.
There was Billie, about six foot three, at least three hundred pounds.
“Is that what happened?” I asked.
“Just like she said,” he replied.
I palpated her abdomen. She was diffusely tender, more in the left upper abdomen. I looked at the monitor: heart rate 130, BP 100/60.
I turned to the nurse.
“Give her a liter of LR and send blood for type and cross and I need a peritoneal lavage tray.”
The nurse pointed to the cabinet, intimating that I should help myself to the tray.
I walked my intern through the procedure. As she slipped in the lavage catheter bright red blood shot out.
“I’d call that positive,” I observed and we pulled the catheter out.
I called my Chief again and Miriam was whisked away to the OR.
I had just made it up to the ICU to check on some of our other post op patients when my beeper went off. The number for the ER popped up.
Will it never end?
 John arrived, hypotensive, complaining of severe abdominal pain. He’d stayed drunk for most of the last three weeks and now he had all the findings of severe pancreatitis. He was admitted to the ICU, required intubation and ventilator support and was dead six days later.  Over the course of his illness he exhibited ten of Ranson’s eleven criteria for predicting mortality from severe pancreatitis. Six or more and mortality is predicted to be 100%.
It was four in the afternoon now and I sensed a lull in the stream of sick and injured. The day wasn’t half over and I’d already done a week’s work.
My Chief called and asked me to come up to the OR where they were about to wheel Miriam in to Room four for her surgery.
“Dr. M is taking a break. Come and do this case with me, that is if the ER has settled down.”
“Seems quiet at the moment. I’ll be there in a minute.”
Performing surgery is always the best part of being a surgeon. I hustled over to the OR and we spent the next hour and half taking out Miriam’s spleen. At surgery it looked like the spleen had exploded, leaving bits and pieces held together by clotted blood.
I hope Billie let’s her be on top from now on.
No sooner had I tucked Miriam away in the Recovery room when my now despised beeper went off and the familiar number to the ER appeared.
Five MVA’s? Give me a break,” I cried, but then headed down to the ER where I spent the next twelve hours.
They were waiting for me, five patients strapped to back boards, faces splattered with blood and bits of glass. Their car had driven off a bridge and plunged about fifteen feet into a ravine.
“Chest X-Ray, Femur X-ray, Pelvis X-ray, CT of head, C-Spine X-ray, start another IV, Type and crossmatch. Let’s go, let’s go. And so we went, nurses and my two interns sat with the patients as they made their way from the ER to X-Ray to the CT Scanner and then back to the ER.
Fractured femurs, fractured tib fib, fractured pelvis, right pneumothorax, left pneumothorax, tension pneumothorax, multiple rib fractures all made an appearance in one of those patients. Call Ortho, call Neuro, call Urology. And with all the injuries, none of those five needed a general surgery procedure outside of a chest tube.
No sooner had I finished shipping the last of the MVA’s off to ICU when Eli came in by ambulance, Gunshot wound to the head. He was breathing, but very shallow, heart rate was 100 and BP was 100/60. There was dried blood on the right posterior scalp and the defect in the skull was palpable. He did not move the left side of his body.
He was intubated with the help of a friendly Nurse Anesthetist and was taken away for CT of his head, one of my interns babysitting. With everything else relatively quiet I kept my eyes on Eli and my intern.
The CT revealed extensive injury to the right posterior brain with bits of bone and bullet mixed in.
I called the Neurosurgeon on call and then prepared Eli to go to OR where he was to have the wounds debrided and ventriculostomy inserted. It was now 8:06 pm and the admission count stood at eleven. The night was still young.
Eight thirty came and went without another call, but eight thirty three brought two more stab wounds, one with multiple abdominal wounds and the other with one to the chest and each arm.
Back to the routine: “Tell me what happened? Do you have any medical problems? Any surgery in the past, any allergies, do you smoke? Drink? Use drugs? Take any medications?”
The abdominal wound was easy to assess as a big wad of omentum was hanging out one the abdominal wall. Antibiotics, type and cross and off to the OR.
The second one had a hemopneumothorax and superficial wounds to the arms. A right chest tube delivered 800 cc blood and then nothing more. The patient was stable, the post chest tube X-Ray looked good and, with any luck, would not need any further intervention. He was trundled off to the intermediate care unit. ICU beds were becoming precious. Two more bad patients and I would need to go begging for beds in the Medical or Cardiac ICU’s.
As if on cue the ER called again. This time it was Barbara, fifty years old with right lower quadrant abdominal pain, nausea, vomiting, elevated white blood count. Everything to suggest acute appendicitis. I called Sara, one of the new interns, to go and evaluate her with the promise that she could do the surgery if Barbara truly seemed to have appendicitis.
Just as Sara ran off, the ER called again, gunshot wound to the leg was coming in. George, the other intern, and I arrived in the ER just as Maurice was being wheeled into one of the trauma rooms. He was awake and screaming. There was a big gauze bandage soaked in blood wrapped around his leg. I started my usual banter and he just screamed, the scent of alcohol permeated the room.
“Let me look at your leg,” I requested with a bit of force in my voice.
“Get the fuck away from me,” he answered.
“How about your foot?” I asked.
“Fuck off.”
I took that as a yes and looked at his foot which was cold, blue and almost lifeless.
“Maurice, I am sorry to tell you that you need to have surgery. It looks like the bullet has injured you femoral artery. If you don’t have surgery you will almost surely lose your leg,” I informed my belligerent patient.
“Fuck you.”
“Does that mean ‘fuck you, I want surgery’ or ‘fuck you, I’d rather lose my leg,” I asked him.
He calmed down for a bit and agreed to surgery and allowed me to finish my survey of him and his injuries. A few minutes later he was up in surgery.
My pager went off again, only this time it was the OR calling. Sara was ready in the OR with Barbara and her appendicitis. I was to assist her, as the Chief was tied up with our stream of trauma patients. I was happy for a respite from the ER, which had reached a brief  lull. I made sure no one was waiting that might need surgery and that there were no injured parties on the way and then I made my way to OR 5.
It was 10:15.
Barbara’s surgery took about an hour as I walked Sara through the appendectomy. She did a fair job. Of course my reprieve from the ER couldn’t last. I had just lain down for a break when the call of the ER came again.
Another stab wound to the abdomen.
Back to the ER where I found Drew, nineteen years old, BP 70/40, heart rate 140, conscious, but barely.
“Need to intubate him and start another IV,” I commanded, going into captain of the ship mode.
The nurse anesthetist easily slid the endotracheal tube in, we ran in a couple of liters of Ringer’s Lactate IV fluid and he perked up a little. Blood pressure came up to 90/60 and heart rate fell to 120.
Poor Drew had a two inch wound in the mid abdomen just above the umbilicus with a small amount of blood pooling. He was pale and thin and palpation in the wound went all the way in the peritoneal cavity.
Blood was hung and I put the call into the Chief.
“This patient needs to go right away. He arrived hypotensive and we’ve got blood hanging now,” I reported.
“Just finished one, three still are waiting, but they’re stable. We’ll come get him now. Keep up the good work,” he answered.
A nice little pat on the head. It’s two am, the bars are just closing.
Why do people feel the need to assert their manhood when drunk? Closing time until about three am is prime time for trauma. Drunk and disorderly takes on new meaning as the nightly revelers leave the safe confines of the pub and saloon and wander into the street. Knives, fists, clubs and guns raise their menacing heads.
“Hey, it’s the Fourth of July…no, it’s now the Fifth of July…people have been partying all day and night. I don’t think there will be many more,” I lied to myself out loud.
Like clockwork the ER called again.
“Two drunk guys with stab wounds, one in the neck, the other in the abdomen, Both look pretty stable.”
I made my way back to there just in time to see the ambulance wheel I a young boy, five years old complaining of severe abdominal pain after being assaulted by his mother’s boyfriend, thrown against the bathroom sink.
Devon looked up at me with bright blue eyes and winced if I even lightly tapped his abdomen. He was otherwise stable, although a little tachycardic with heart rate 120.
I also quickly evaluated my two stabbing victims, who, it turned out, had stabbed each other over the matter of twenty dollars and a pool match. The neck was mid neck, had penetrated through the platysmal layer and would best be treated with exploration. The abdominal stabbing also penetrated fairly deeply and would also need to go the OR.
I talked with the Chief again, who came to evaluate the child. As I was talking with him my intern put up the boy’s Chest X-ray which revealed free intraperitoneal air.
“One more for the OR,” I stated. My Chief just sighed.
“How many is that?” I wondered out loud. We’d both lost count.
Over the next few hours three more MVA’s arrived, all with a variety of fractures: ribs, femurs, humerus, tibias, fibulas, but nothing that would need general surgery.  I tucked them away to await their Orthopedic procedures and then went to make morning rounds.
It was six am.
With my two interns in tow we started in the ICU, visiting the myriad pre and post op patients whom we had met in the twenty four hours we’d been on call.
As we finished my Chief called.
“Dr. M is tired and he’s leaving. We’ve got three more patients to explore. The stab wound to the neck, and two stab wounds to the abdomen. Come on over to the OR so we can knock these out.
So after spending almost an entire day in the ER I finished up in the OR, Exploring a  neck which had only a lacerated anterior jugular vein and a tiny tear in the thyroid cartilage, then doing exploratory laparotomies on two patients where I repaired six holes in the small bowel, resected a short segment of colon and did a colostomy.
We checked on a few of the sicker patients before we left.
It was 3:25 in the afternoon.
By my count I had admitted twenty five patients, mostly seriously ill and injured.
Jose had suffered injury to his liver, colon and mesenteric artery.
Miguel had been shot in the colon, stomach and pancreas.
Miriam had shattered her spleen after her three hundred pound boyfriend had jumped on her spread eagled naked body.
Maurice had suffered injury to his right femoral artery and vein. His leg was saved, but that didn’t improved his personality at all.
Eli survived his surgery, but succumbed forty eight hours later.
Drew survived injury to his diaphragm, stomach, spleen and left kidney, walking out of the hospital after a two week stay.
Devon suffered a perforation of the third part of his duodenum and a laceration of his pancreas. Timely surgery allowed the injuries to be repaired and he recovered uneventfully. His mother’s boyfriend went to prison for five years.
All in day’s work.