Trauma Surgery
Yousif Z. Alkadhi
This experience occurred early into my trauma surgery month, and while I guess I was expecting devastating trauma and life-and-death experiences, I don’t think I was quite prepared for this.
The patient was an African American male in his mid-40s. Apparently, he had run a red light that morning on the way to work and hit a dump truck with his small car. From pictures I saw later, it didn’t seem that too much damage was done to his car, even though it rolled the fully loaded dump truck over. When the trauma page went off, I was actually excited for a quick moment. Unlike my first week on the service when I felt lost and overwhelmed, I had just recently reviewed the algorithms for blunt abdominal trauma in stable vs. unstable patients, and I felt like this would be a great learning experience and a chance to put what I’d learned to use.
I don’t remember whether the patient was already intubated when he arrived. I do remember that he had started to wake up and struggle and the person manning his airway had tried to calm him down. He had told him that he was okay, that he was at the hospital and that we were taking care of him.
A questionable FAST exam plus inconsistent vitals (a systolic that ranged from 80 to 170) lead us to the CT scanner. It was finally in the OR that we realized what had happened: the patient had numerous liver lacerations and a ruptured diaphragm. At that point, things were still going well. Just last week, we had done a splenectomy on a guy the morning after he had survived a night that included a thorough beating, a car accident on the ride home, and sleeping on his mom's couch. Surely, I thought, this patient, who had sustained his injuries less than an hour ago, would be alright.
It was after they'd repaired his diaphragm and most of the large tears in his hepatic veins that the attending asked me to call interventional radiology and get them on board. I could tell the situation had gone from being manageable to maybe not so much. They couldn't stop the bleeding, and while at first we were able to keep up with his pressures, the fluid losses just kept coming (we ended up ordering 38 units in total). By the time we had closed his abdomen and were ready to go to the IR suite, anesthesia was worried we wouldn't make it out of the room. It was when I watched his pressures drop to 50s/30s and his O2 sat dip below 79 that I realized that nothing is a given and that this guy might need some help. I asked God to look out for him.
By the time we made it to the IR suite, the patient was pretty much getting 1mg of epinephrine, roughly every 2 to 3 minutes. His A-line read 40/20, although I think they got it back to 65ish/something a moment later. After lots of looking, IR finally found a leak in one of his arteries. I couldn't exactly tell where it was, but it didn't matter; after 3 tries, they couldn't get any tools in to embolize it because his vasculature was so constricted from all the life-saving epi he'd received. The goal now was just to get him to the ICU alive so his family could see him.
I think we used 3 or 4 more doses (as many as we had) of epi in the hallway and on the elevator up to the ICU. We finally got up there and at last, I was relieved...I thought we'd made it and the job was over. Little did I know. The RN asked if the patient was a full code, because he didn't have a DNR. Obviously, I was certain he wasn't. Cardiac arrest was not what this man was dying from. As one of the attendings said downstairs, he was just metabolically exhausted. No amount of ACLS was going to make a difference.
But, as he began to code, lo and behold, we started ACLS. Three of my classmates and I rotated on chest compressions. Still, I was fine. I'd done compressions the other day. I was alright with the fact that he was dying; so did the last guy I did compressions on. It's a little graphic, but I was still cool. I was still cool with the fact that his abdomen was open, held together with what looked like brown Saran Wrap to me, and that with every compression I made, his abdomen felt as though it bulged open more and more. While both his atria were filled to the brim and not connected to suction, every chest compression caused more fluid to squirt out of them and onto us and the floor where we were standing.
So, there I was—we'd been doing compressions for maybe 5 or 10 minutes, and finally the family made it upstairs and was asked if they would like to watch. It's while I was on compressions that they started to come in. The first person in was a large older woman. All I remember is that she went over and started tapping on the patient’s left arm and calling out to him by name, telling him to "Come on!!! Don't do this!!! Come on now!!!" Someone else then started praying loudly, shouting out for Jesus. It was intense, but we kept it together, going and rotating for 5 or 10 more minutes. One of his family members fainted. There had to have been close to 25 different family and church members there by the time we got to the "Does anyone have any other ideas?" part of the code.
The worst part was how horrible I felt, as though we were putting on a show. We knew he wasn’t coming back. It had been almost 3 hours since the accident. I thought to myself, “God, I hope my family is never subjected to watching this.” However, according to studies I've heard about, watching a code brings closure for the family. Perhaps they have a bit more peace knowing all that was done for their loved one. It wasn't until I went home that night and cried to my wife that I started to have closure for myself.