But the most unusual type of patients, the fleetingly rare ones, are the patients who come in dead and leave alive. Those are the patients whom we as a trauma team consider not just a Good Save, but a Great Save. They are the ones that stick in our memory, the ones we talk about for years to come when swapping war stories and trying to one-up each other. They are the Holy Grail of trauma, each one a once-or-twice-in-a-career event.
And I almost had one of those. Almost.
Dale (not his real name™) was one of those rare stabbing victims that was not brought in at 2 AM. Somehow he had managed to get stabbed at 7:30 in the evening when most people are either eating or getting ready for bed (I guess . . . at least that's what I am usually doing at that time). I haven't the slightest idea what Dale was doing or who stabbed him, but whoever it was wanted Dale dead. He was called in as a code-in-progress, meaning his heart had already stopped en route. When the medics got him to me about 30 minutes after he was stabbed, they looked a bit frantic and completely exhausted.
"Hey Doc, (pant pant) this is Dale. He's 20-ish, (huff puff), one stab wound to the right upper chest. Huge amount of (puff puff) blood loss on the scene. He's been down for about 30 minutes. We couldn't get an IV on him but we got him (puff puff) intubated."
One three-second glance at Dale told me two very important things: 1) Dale had seemingly exsanguinated from a single stab wound to the right upper chest, and 2) Dale was dead. He had no pulse (meaning his heart was either not beating or not beating hard enough to generate a blood pressure), and his pupils were both 4 mm and non-reactive, meaning his brain was critically deprived of oxygen. But in addition to all that, Dale was also cold. Very cold. His core temperature was about 32° C (about 90° F), but when we put him on the cardiac monitor he still had some cardiac activity (a condition known as pulseless electrical activity).
His heart was trying to beat, it just didn't have any blood to pump.
The easy thing to do in this situation would have been to call the code and pronounce Dale dead. Because he was dead. However, I chose not to do the easy thing for two very good reasons:
- Perhaps with some oxygen-carrying capacity (read: blood) Dale could be revived (however unlikely that may be), and
- you're not dead until you're warm and dead.
As nurses were getting a couple of large-bore IV's started, an assistant was inserting a chest tube into his right chest which yielded very little blood, which meant he had bled out into the outside world (as the medic had indicated), not into his chest. We continued doing CPR and very quickly squeezed two warmed units of blood into him, and immediately afterwards I heart someone yell something that gave me significant pause:
"I GOT A PULSE HERE!"
Somehow, Dale now had a measurable blood pressure. And with that blood pressure he now resumed bleeding torrentially from his stab wound, which was obviously a lacerated subclavian artery. SHITSHITSHITSHITSHIT This is one of the most difficult injuries to repair, as the approach is extraordinarily complex. So I did the only thing I could do in that moment: I stuck my finger in the hole.
This was extremely effective at controlling the bleeding while we continued transfusing him, but it is also extremely temporary. I shouted for the operating theatre to get ready for us, because the only thing that could save Dale's life was a sternotomy.
One very large question remained, however: was his brain already cooked? His brain had been deprived of oxygen for at least 45 minutes, but I had no time to find out just then. That would have to wait until either A) I got the bleeding stopped or B) he was really most sincerely dead.
By some minor miracle Dale's blood pressure held as we wheeled him to theatre, my finger remaining firmly planted in the hole the entire time as I dodged door frames and wall corners. Once in theatre I made a quick 1-second finger switch with an assistant so I could scrub. Ten minutes later I was sawing through Dale's sternum, and his heart was staring me in the face, pumping away.
I got control of his brachiocephalic artery first, then I extended the incision across his right upper chest towards the entrance wound. I continued dissecting the artery distally until I got to the point where his subclavian artery split from his common carotid artery. Finally I had proximal control. Unfortunately that was only half the battle, and even more unfortunately it was the easy half. Now I had to get distal control, which was a much more difficult prospect.
The dissection towards the wound continued, my assistant's finger still plugging the hole. To get access to the injury, however, I had to remove the middle section of the clavicle (and my assistant's by-now very cramped finger). Once this was done the injury finally came into view as it was audibly bleeding. Yes, I could actually hear the blood rushing out. Somehow the knife had missed the subclavian vein and had hit only the subclavian artery. With the artery now clamped both proximal and distal to the injury, I carefully placed a few sutures in the artery, trying to stop the hæmorrhage but still maintain some flow into the right arm. My main objective, however, was to stop the bleeding, not to save the arm, which was a distant secondary goal (life over limb).
Just like that, the bleeding stopped. Voilà! Success! I took a few minutes to exchange high fives all around (not really) before thoroughly checking for other injuries (there were none) and closing. But as I closed him that one big question still hung over everyone's head:
THE BRAIN. What was the status of Dale's brain? I had no way to predict how his brain would react to prolonged oxygen deprivation before we had been able to get his heart restarted.
Over the next two days his blood pressure stabilised, he stopped bleeding, and he actually began to open his eyes. On the third day I was stunned and even cautiously optimistic to find that he even seemed to follow some simple commands.
A Great Save! Huzzah! We did it!
The optimism wouldn't last.
Now that he was stable we were finally able to get a CT scan of his brain, and finally the devastation of his brain injury became apparent. He had widespread ischæmic damage to his entire cerebellum and various large portions of his cerebrum with extensive œdema to the point where his brain was starting to push his brainstem down into his foramen magnum (so-called transtentorial herniation).
My cautious optimism immediately vanished. Dale was actively dying again.
There was but one option left and it was a drastic and rather terrible one. But I had no choice because Dale was in immediate danger of dying. Again. In a last-ditch effort to save him, one of my neurosurgery colleagues took him back to theatre to remove a portion of his skull to give his brain space to swell and allow the herniation to improve.
It didn't work. Two days later he was completely unresponsive, his pupils were both blown, he had lost his cough, gag, and corneal reflexes, and both an apnœa study and brain flow study confirmed that he was brain dead.
GOD DAMN IT.
I went through the entire gamut of emotions during Dale's course, from frustration to elation, worry to optimism, fear to dejection. Just when I thought Dale was dead, he came back, and just when I thought he would make it, he didn't.
The entire time I worked on Dale, every single moment, my Inner Pessimist kept reminding me that he had a 99% chance of dying. But goddammit that also meant he had a 1% chance of surviving. While that isn't very high (obviously), it also wasn't zero.
Until it was.
By some minor miracle Dale's blood pressure held as we wheeled him to theatre, my finger remaining firmly planted in the hole the entire time as I dodged door frames and wall corners. Once in theatre I made a quick 1-second finger switch with an assistant so I could scrub. Ten minutes later I was sawing through Dale's sternum, and his heart was staring me in the face, pumping away.
 |
| Not actually Dale's heart |
I got control of his brachiocephalic artery first, then I extended the incision across his right upper chest towards the entrance wound. I continued dissecting the artery distally until I got to the point where his subclavian artery split from his common carotid artery. Finally I had proximal control. Unfortunately that was only half the battle, and even more unfortunately it was the easy half. Now I had to get distal control, which was a much more difficult prospect.
The dissection towards the wound continued, my assistant's finger still plugging the hole. To get access to the injury, however, I had to remove the middle section of the clavicle (and my assistant's by-now very cramped finger). Once this was done the injury finally came into view as it was audibly bleeding. Yes, I could actually hear the blood rushing out. Somehow the knife had missed the subclavian vein and had hit only the subclavian artery. With the artery now clamped both proximal and distal to the injury, I carefully placed a few sutures in the artery, trying to stop the hæmorrhage but still maintain some flow into the right arm. My main objective, however, was to stop the bleeding, not to save the arm, which was a distant secondary goal (life over limb).
Just like that, the bleeding stopped. Voilà! Success! I took a few minutes to exchange high fives all around (not really) before thoroughly checking for other injuries (there were none) and closing. But as I closed him that one big question still hung over everyone's head:
THE BRAIN. What was the status of Dale's brain? I had no way to predict how his brain would react to prolonged oxygen deprivation before we had been able to get his heart restarted.
Over the next two days his blood pressure stabilised, he stopped bleeding, and he actually began to open his eyes. On the third day I was stunned and even cautiously optimistic to find that he even seemed to follow some simple commands.
A Great Save! Huzzah! We did it!
The optimism wouldn't last.
Now that he was stable we were finally able to get a CT scan of his brain, and finally the devastation of his brain injury became apparent. He had widespread ischæmic damage to his entire cerebellum and various large portions of his cerebrum with extensive œdema to the point where his brain was starting to push his brainstem down into his foramen magnum (so-called transtentorial herniation).
My cautious optimism immediately vanished. Dale was actively dying again.
There was but one option left and it was a drastic and rather terrible one. But I had no choice because Dale was in immediate danger of dying. Again. In a last-ditch effort to save him, one of my neurosurgery colleagues took him back to theatre to remove a portion of his skull to give his brain space to swell and allow the herniation to improve.
It didn't work. Two days later he was completely unresponsive, his pupils were both blown, he had lost his cough, gag, and corneal reflexes, and both an apnœa study and brain flow study confirmed that he was brain dead.
GOD DAMN IT.
I went through the entire gamut of emotions during Dale's course, from frustration to elation, worry to optimism, fear to dejection. Just when I thought Dale was dead, he came back, and just when I thought he would make it, he didn't.
The entire time I worked on Dale, every single moment, my Inner Pessimist kept reminding me that he had a 99% chance of dying. But goddammit that also meant he had a 1% chance of surviving. While that isn't very high (obviously), it also wasn't zero.
Until it was.
