Tuesday, 9 June 2015

Sad

I hate the Call Gods, and they know it.  They only rarely ignore me, so usually they have their sick little fun by torturing me either by being evilly funny or funnily evil.

And sometimes they completely forgo humour and are just plain cruel, though not necessarily to me.

I don't typically keep statistics on my call days, but this particular day was so sad and so bizarre that I just couldn't help myself: I had a total of 8 patients, with 7 survivors and 2 deaths.

Wait doc, you said it was only 8 patients!

Yes I did.  Now before you think I'm the worst mathematician in the history of the world, I'll explain.  But then, you already knew I would.  So shush and read on.

My day started off so slowly, just an early morning bicyclist who lost control but managed to break his fall with his face.  The pavement was significantly harder than his face (as it always is), so he suffered several facial fractures, abrasions, and lacerations.  His brain fortunately was fine, so he would live.  I wish I could say the same of all my patients that day.  Yes, that's foreshadowing.

Eight hours then went by with nary a call, but then the Call Gods sent me a page that included a single word that instantly puts fear into any trauma surgeon's heart:

PREGNANT

Pregnant patients are generally treated the same way initially as any other patient, though with one major proviso: take care of the mother first.  If you think that sounds either callous or uncaring towards foetuses, think of it this way - when you're flying, they tell you to put your own oxygen mask on before helping others.  Why?  Because if you pass out while trying to help others (since you didn't put your own mask on first), you will then be unconscious, and therefore unable to help anyone.  The same goes with pregnant women - if the mother dies, the foetus dies with it, so help mum first.  Though the basics are the same, the finer details of the workup do get tweaked a bit around the uterus, however.  Ultimately we do everything in our power to save both patients, but if a choice has to be made, we save mother first.

When Jacqueline (not her real name©) arrived in my trauma bay about five minutes later, she was clearly in a great deal of discomfort.  She was 8 months pregnant with her first child and had been riding in the rear-left seat of her car (with her seatbelt on, fortunately) when her door was struck by another car at high velocity.  Unfortunately she lived a good distance from my hospital, so she had to be flown by air ambulance, which took about an hour including the time it took to extricate her from the car.  She was mainly complaining of left chest pain and lower abdominal pain.  And there was bruising around her lower abdomen.

OH . . . SHIT.

Her vital signs were all reasonable and her ABCs all checked out, so I made the quick assumption that she was not actively dying.  While others rushed to attach monitors, check her vital signs, and start the head-to-toe evaluation, I grabbed my ultrasound machine (which I normally use to assess for any signs of internal bleeding from the spleen or liver), squirted the gel on her belly, and looked for the foetus.  It obviously wasn't difficult to find, but it wasn't moving at all.  Hoping it was just asleep, I found the foetus' chest to look for the heartbeat.  There it was . . . and nothing.

Shit shit shit shit shit shit shit shit shit

The obstetrics team had just arrived, so as they gathered all the necessary equipment for an emergency Cesarean section, I finished my ultrasound examination, looking for any signs of internal bleeding.  The only abnormality I saw was a big air pocket in the left chest, which is usually indicative of a pneumothorax (a collapsed lung).  Usually.  Foreshadowing abounds.

The obstetrician laid her hands on her belly and somehow immediately diagnosed the problem: placental abruption.  The accident had caused the placenta to separate from the uterine wall, and the foetus had been deprived for oxygen for over an hour.  As I stood there with my mouth agape, a detailed (though quick) ultrasound confirmed the intrauterine foetal demise.  The baby was dead.

Not Jacqueline's actual X-ray
All the noise in the trauma bay suddenly turned into absolute silence.  I stood back in stunned disbelief as the obstetrician gave Jacqueline the bad news.  As Jacqueline began sobbing, and as heartbreaking a moment as it was, I realised I still had a very sick patient to treat.  I couldn't afford to let her (or me) get sidetracked by the tragedy.  After allowing a few moments of grieving, we got a chest X-ray which showed that the air in her chest wasn't a collapsed lung at all.  I personally took her over to the CT scanner, which confirmed the diagnosis - that the air pocket in her chest turned out not to be a collapsed lung, it was her stomach.

The obstetrician then asked me to delay the surgery until the next day after she deliver the foetus vaginally.

No, I told her quite firmly.  She needed immediate surgery for her ruptured diaphragm.  It takes a relatively high-energy impact to rupture a diaphragm, and that sort of impact can injure any other abdominal organ as well.

I took her straight to the operating theatre where I opened her abdomen from top to bottom.  The uterus was taking up the majority of the space in the peritoneal cavity, so the obstetrician and I first delivered a beautiful little girl via Caesarian section.  After we removed the placenta she started suturing up her uterus, and despite my best efforts my eyes kept wandering to the crib that the neonatology team had brought into the room.  All I could see was a pale, immobile foot.

No no no, I still have work to do.  Focus, damn you.

The tear in her diaphragm was rather large, about 14 cm, big enough for her entire stomach to get through.  I pulled her stomach back into her abdomen and repaired the diaphragm.  Fortunately I found no other injuries, so I closed her up.  That was the easy part.  The hard part was next . . .

Telling her husband and her mother.

Many tears and hugs later, I trudged back to the trauma bay, feeling worse than I had in years.  My thoughts kept going to my own children and how I would have reacted had my wife been injured when she was pregnant.  Ok Call Gods, I thought grimly, that's the worst tragedy you assholes are going to throw me today, right?

No.  No it was not.

Just before midnight Carl was brought to me with a gunshot wound to the back of his left shoulder.  And no heartbeat.  He had been awake and breathing when emergency services first got to him, but en route his heart stopped.  As soon as he arrived I opened his left chest widely and saw the the bullet had entered his shoulder, gone into his chest, through his lung, and into his spine.  His entire blood volume was in his chest, and there wasn't a damned thing I could do except to pronounce him dead.

And that's how out of eight patients, I got seven survivors, two losses, and a huge desire to hug my wife and children the second I got home.

9 comments:

  1. I don't know if I can stop crying, that is absolutely heart-wrenching! My prayers go out to the mother and her family. Loosing a child is every mother's worst fear and it is something I would never wish upon my worst enemy.
    How you kept your composure is beyond me, Doc, but on behalf of the family, thank you for saving the mother's life.

    I know you get this a lot – almost to the point of it being a cliché – but I'm going to say it anyway, you are an incredible Doctor and amazing individual who genuinely cares for his patients; I wish there were more Doctors out there like you.

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    1. I completely agree!!

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  2. This reminds me of the rule about where you start a triage operation: "right here"

    you start with the first patient you come to and go progressively from there until you've checked them all. with a pregnant patient, you also start with the first patient you come to.

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  3. Such sadness. I hope the mother and father will be able to deal with this tragedy and not put the blame on themselves. I hope that if I ever have to be taken to a trauma unit, my doctor will be as compassionate and skilled as you are.

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  4. The greatest fear during my pregnancies always was that for some reason the baby could die inside me and there was nothing I could do about it. Reading this makes me even more thankful that everything went well. I can't even start to grasp the devastation they must feel at such a loss.

    Doc, see this is exactly the reason I didn't go into medicine although I always found it really intriguing. I'm pretty sure the tragedy would have reduced me to a sobbing mess right there. I am truly in awe that you managed to still function and save the woman's life.

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  5. What an awful day. I only hope the Call Gods decide they've had sufficient sport with you and ease up.

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  6. I cannot imagine being in your shoes in that situation. To focus on the patient in front of you when your family keeps pushing their way to the forefront is a testament to you as a physician. It is a challenge to say the absolute least.
    ~AnonRN

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  7. Doc, thank you for sharing your best and worst days. Your patients are lucky to have you

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  8. The farther along in pregnancy that I got, the more anxiety I had about losing my baby :( it's so scary knowing you've carried a little life for eight months and a split second decision from someone else could end it at any moment :( my heart breaks for that family, and I hope they could get through it together. I don't think we could have.

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