Thursday 7 August 2014

Too much

Taking a trauma shift is a bit strange.  It's difficult to describe the feeling of sitting around, waiting for something to come in, not knowing what that "something" is or when it will be here.  The mantra in the Trauma Universe is "Eat when you can, and sleep when you can."  Growing up with two much larger brothers certainly taught me to eat quickly, otherwise I'd have starved to death.  But unfortunately my body has never properly embraced the "sleep anywhere" concept.  I regularly see my colleagues catching a 5 minute catnap in the lounge with their head in their hands, but unless I'm in a dark, quiet room, my brain likes to do things like try to come up with new palindromes and anagrams despite my efforts to tell it to shut the fuck up.  Though my body likes to sleep, my brain likes to keep me awake and doesn't know when enough is enough.

On one such night after a fairly uneventful day, I had just put my head on my pillow in my dark, quiet call room when my brain thought it would be a perfect opportunity to have a lively philosophical debate about why nothing much had happened that day.  Barely five minutes later . . .


Of course.  At 11:30 at night, what else could the call possibly be but a high-level gunshot victim.  Oh Call Gods, you are a funny bunch of bastards.  Your sense of comedic timing is absolutely spot-on, and I love how I can always count on you to give me a big "FUCK YOU" whenever I need one.  Sleep would obviously have to wait.

You win this round, brain.

I walked quickly down to the trauma bay, and the young guy that arrived a few minutes later looked like he was on the verge of death.  "Ok Doc," the medic started.  "We have an 18-year old kid.  Multiple gunshot wounds to the head, chest, abdomen, back and thigh."

"Someone sure wanted him dead," my Inner Optimist told me.  "But he still has vital signs!  Maybe he'll be ok!"

Now is not the time, Inner Optimist.  Fuck off, I have work to do.

The anaesthesiologist immediately got to work getting a breathing tube in and there were a dozen people milling around his head, so I looked at him from the feet up.  There was a rather large hole on the front of his left thigh and another (possibly an exit wound) on the inside of his thigh.

"Not too bad, maybe a fractured femur.  Away from the femoral artery, at least.  That won't kill him."

Shut up, you.  In the abdomen there was a gunshot wound just below the rib cage on the right and a second one just above the lower edge of the ribs on the left.

"Uh oh, that's not good.  There's potentially a lot of very important stuff between those two holes - liver, stomach, small intestine, colon, spleen, diaphragm, lung.  Any or all of those could kill him, but don't worry, we can fix it!"

My Inner Optimist was starting to piss me off.  Continuing upward he had two holes on the left side of his chest, but they looked like simple graze wounds.

"At least we won't be cracking his chest.  That's something, right?" 

Two holes on the back of his left shoulder.

"Who cares.  That's not serious at all.  Move up.  Look at his head.  It's probably nothing!"

By now I was ready to throw my Inner Optimist out the window.  I got up to the patient's head and saw an entrance wound in his right temple and an exit wound on the left.  That was the exact point when my Inner Optimist ran out of the room yelling "SHIT!!!!!".  Finally.

Transcranial gunshot wounds are almost universally fatal.  There are some surgeons who wouldn't bother operating on patients like this to repair damage to the abdomen, simply because there is such a low probability, right around 0%, that he would survive the brain injury.

I'm not one of those surgeons.  While it's true that most patients die within hours, I've seen a handful of patients with severe brain injuries survive and even wake up to varying degrees.  My heart had to admit to my brain that this kid's chance of living was fleetingly low, and even though my brain may have been ready to give up on him, my heart wasn't.

This is one of those times when I wish I could have listened to brain instead of my heart.

When I opened him up I found almost exactly what I was expecting - the bullet had ripped off a chunk of his liver, gone through his colon twice, torn 4 holes in his small intestine, and gone through his diaphragm before finally exiting.  I repaired every hole I found, only losing about 100ml of blood in the process (that's a bit over 3 oz, a very small amount for this big an operation).  I was starting to feel pretty good about myself until I looked down at my shoes and saw that I was standing in a puddle of blood.

What . . . where . . .

While I had been repairing the damage in his abdomen, he had poured about a liter of blood from his ears onto the floor.  Needless to say, that's not good.  Despite the multiple blood products the anaesthesiologist had given him and normal blood counts, his blood pressure was bottoming out and his heart rate was slowing down.  His pupils were fixed and dilated.  It was glaringly, painfully obvious that, because of the injury to his head, his brain had swollen to the point where it had lost its blood supply.  He was dying, fast, and there wasn't a damned thing I could do to stop it.

I closed up and resigned myself to his fate.  My brain had been right - the head injury had been too much.  Way too much.  I had done everything I could do, and it wasn't even close to enough.  I went out and talked to his family and told them the bad news, that it was time to start saying their goodbyes.  His mother was desperate, asking if anything else could be done.  "Would antibiotics help?"  I couldn't blame her for the question in this moment of despair.  I calmly explained that he had too many injuries.  It was just too much.  Too much.

She seemed to understand and went to her son to say goodbye.  An few minutes later, he was gone.

My brain didn't allow me to sleep at all the rest of the night.


  1. There was a car crash. two passengers belted, one unbelted. when I got there, the medics (first in) had all three on the roadway. (to what degree they got there under their own power, I don't know.)
    one conscious and helping the medics with one unconscious - and they assigned me the third - breathing and in and out of consciousness.
    they began rescue breathing on the unconscious one, preparatory to CPR, and the result they got was bleeding from the ears. as I recall, the conscious passenger said to the medic, "That's bad, isn't it?"
    It was. it is what we call a trauma code - cardiac arrest due to trauma. Usually, there's nothing anyone can do to bring them back. (not that we don't try, if we think there's any chance at all)

    oh, and because the emergency services culture mandates redundant PSAs, guess which one was the unbelted one.

    1. as for the sleep - I understand fully - I almost never sleep within an hour of ANY significant call - and a major one will keep me up longer. - barring physical collapse.

    2. I am. my colleagues package these people for the medics to haul off to visit DocB's colleagues.

    3. Nice. Thanks for what you do man.

    4. Thanks. most of us do it because we love it, but it's always nice to not be taken for granted.

  2. Why didn't you open the skull so pressure would not build

    1. I'm guessing the answer will be that it would be too little, too late.

    2. Also worth noting that there were already two holes in his skull before Doc B' even got involved so a little pin-hole was hardly going to make a difference. I have no idea whether it's feasible to take half the guy's skull off but they are professionals and I'm sure they would have considered it.

      "he had poured about a liter of blood from his ears onto the floor. Needless to say, that's not good." Understatement of the week there Doc'!


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