Thursday 27 March 2014

Mass casualty

Give me your tired, your poor,
Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore.
Send these, the homeless, tempest-tost to me.

The above poem, "The New Colossus", was written by Emma Lazarus in 1883, and it became one of the world's most famous verses after being inscribed on a plaque in the Statue of Liberty outside New York City.  Thousands of immigrants were greeted by this poem upon entry to the United States, but the words could just as easily be inscribed above the door to my trauma bay.  I seem to have a knack for attracting the huddled masses, but my forte is definitely attracting the wretched refuse, and they all appear to enjoy coming to meet me on the same night.

A trauma surgeon's worst nightmare is a mass-casualty event - a train derailment, a plane crash, a collapsed apartment building, a Justin Bieber concert.  Fortunately in most places around the world, these events are fleetingly rare, but we run training simulations on such possibilities nevertheless.  One of the most difficult things to do in a mass casualty event is triage - rapidly assessing which patients are the most severely injured but who are also salvageable.  Taking too much time 1) doing CPR on the guy with the open head wound and brain matter leaking onto the gurney, or 2) suturing a knee laceration on the lady who is otherwise mildly injured, decreases the survival chance of the guy with a metal pole sticking out of his abdomen.  The first patient has essentially no chance of survival no matter what I do, and the second patient clearly will be fine.  But the third patient also has a decent shot of living, but only if he receives immediate attention.  That is the art of the triage - not only who needs fixing, but who needs it first.

So naturally the burning question in everyone's mind at this point is (or should be), "Have you ever been in such a situation, Doc?"

Well, no.  Not exactly.  Actually, sort of yes.  Not really.  Kind of.  Ok, a bit.

After a boring first twelve hours of a 24-hour shift, it seemed nothing exciting would happen that day.  Fortunately I knew better than to taunt the Call Gods by mentioning that little tidbit.  The Call Gods, in all their malevolent glory, didn't need any such taunting, however.  At 8:30 in the evening my pager interrupted my viewing of the latest episode of "Sherlock", telling me I would be getting a level 2 (not as serious as level 1) gunshot victim in 5 minutes.  My pulse quickened slightly as I made my way to the trauma bay, but it quickened even further a minute later when my pager informed me of a second gunshot victim, this one a level 1, also in 5 minutes.  As I walked into the trauma bay, my pulse reached very near Full Blown Panic Mode when they wheeled in a third gunshot victim, also a level 1, who had been dropped off at the hospital by his buddy.


I started looking at the first victim, and the second guy (the level 2) was wheeled in less than a minute later.  I started my silent internal triage as I examined the first one - he had been shot in the abdomen, but it was a seeming glancing blow from near his flank through to his back.  His abdomen was soft and essentially pain-free when I pushed on it, a sign that he was probably not seriously injured, and I triaged him to the back of the line for now.  As I was running to see the second guy (who was now vomiting blood on the floor), the third one was wheeled in, a medic straddling his pelvis while performing CPR.


A 2-second glance at the second victim revealed two gunshot wounds in his abdomen, one near the umbilicus (belly button) and a second (presumably an exit wound) in his left flank.  But as opposed to the first victim, this guy's abdomen was rigid and he screamed when I touched him there, a sure sign of peritonitis.  My silent triage continued - this guy was salvageable, but something extraordinarily bad was happening inside his belly, and I clearly needed to be in there RIGHT NOW.  But I also needed to see what was going on with the third victim RIGHT NOW.


I instructed the nurse to wheel victim #2 directly down to the operating theatre, and I yelled to one of my assistants to call the operating room and tell them the patient was coming.  I then ran to the third victim who had been shot in the left chest.  He had no pulse, but I had no idea how long he had been down.  What I DID know was 1) I had around 10 minutes while victim #2 was wheeled to the operating theatre, put to sleep, and readied for surgery, 2) this guy statistically had a 99% chance of dying, and 3) his chance of death increased to 100% if I didn't do anything.  My only option was to do a resuscitative thoracotomy (ie "crack his chest") to expose his heart and lungs and try to do something . . . anything to bring him back to life.

It took me about 30 seconds to put on my gown, gloves, and mask, another 60 seconds to get into his chest, and then an additional 2.17 seconds (I counted) for his entire blood volume to pour out of his chest onto my feet (which were mercifully covered with shoe covers).  I did a quick survey of his chest, and the bullet had ripped through his left lung, tearing a major branch of the pulmonary artery and causing him to bleed to death internally.

One minute later I was halfway to the operating theatre, having declared victim #3 dead as I removed my shoe covers, then re-examined victim #1 to make sure my initial assessment was correct (it was), and finally barking various orders to the nurses and assistants.  I got into the operating theatre just as the nurses were finishing applying the sterilising solution to his abdomen.  I took a deep breath, realigned my chi and chakras, and slashed his abdomen open with the ferocity of a 1000 lions.

An hour later I had successfully repaired several holes in his stomach and colon, so I started congratulating myself on a job well done.  Then my Internal Pessimist reminded me that I had just pronounced a man dead (and still needed to inform his family), I still had a gunshot victim in my trauma bay who may or may not need surgery (he didn't), and there were still 10 hours to go in my shift.

I fucking hate my Internal Pessimist.  But the little shit was right - I had two more gunshot victims later that night.  One of them was shot in the leg, the other in the head.  One of them survived.

This was a night I won't soon forget.  It's the closest I've come to a mass casualty event, and hopefully the closest I'll ever come.  

. . . Until my daughter asks to go to her first One Direction concert.  Maybe I can get my Internal Pessimist to take her, and I can stay home and watch "Sherlock".


  1. Hope you got to finish watching "Sherlock"! Awesome show. Can't comment about the "victims" though. Stupid people doing stupid things. sigh

  2. Wowzers! That's some day at the office! Good work Dr B'.

    Just out of interest, what would have happened if you found CPR guy was salvageable? Clearly you then have two patients actively dieing and both seemingly needing your full attention immediately. Would you have a colleague to call who could pick up one, or would you have had to choose which one had the better chance? Sounds like peritonitis guy had the better odds but it must be heartbreaking to have to choose.

    Oh and I've just discovered Sherlock (don't really get to watch much TV). Great isn't it.

  3. PS did you open CPR guy right there in the the trauma bay? That really does sound like an emergency measure!

    1. Yes I did. Desperate times call for desperate measures.

    2. You don't get a lot more desperate than that!

  4. With all of those gunshot vicims, it sounds like a typical Saturday night in Oakland, California.

  5. How often do you lose a patient? Two in a night seems like quite a lot.

    1. It was more than usual. I lose perhaps a patient per month, but it varies wildly.

  6. How did the triage happen in the first place?

    1. If you're asking about the situation surrounding the shootings, I haven't the slightest idea.

  7. You need to begin convincing your daughter that Benedict Cumberbatch is vastly sexier, and smarter, and any of the members of One Direction. You'll save yourself hundreds of dollars, and a huge headache.

  8. When I was stationed at FT Campbell, KY in 1996 I was at the hospital getting various vaccinations. Meanwhile the bulk of the hospital staff were conducting a MASSCAL exercise when two Blackhawks fully loaded with soldiers collided. Since they already had all of the extra personnel and equipment out it was a blessing. The problem they did have was convincing everyone it was not a drill but a real emergency.


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