Monday, 12 February 2018

Almost

It should come as no surprise that most of my patients, well over 90%, come in to my trauma bay alive and leave the hospital the same way.  Don't worry, I'm not patting myself on the back here.  It isn't because I'm some sort of spectacular trauma surgeon, but rather because most of these people are just not critically injured.  The ones who are critically injured but still survive are what I consider the Good Saves, the ones I occasionally share with you good people.  Rarer than this (luckily) are folks that come in dead and stay dead.  Fortunately very few people come in alive and leave via the morgue.  I sometimes share those stories too. 

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:
  1. Perhaps with some oxygen-carrying capacity (read: blood) Dale could be revived (however unlikely that may be), and
  2. 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 arterySHITSHITSHITSHITSHIT  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. 
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.

14 comments:

  1. tough loss, that.
    consider our side of the story: we get the patient, package them for shipment, hand them off to the paramedics, sometimes send a rider along, and if they have a pulse at the ER door, that is usually the last we see of them. because of HIPPA, we are usually in the doesnt-need-to-know group, and so it is very rare for us to know if our save was ultimately successful.

    like one we had. we responded to a medical issue, which was converted to code while we were en route. when we arrived in the area, we were confronted by the ambulance crew staring at a virtually impassable road. fortunately, we were driving a virtually unstoppable piece of equipment, so we transferred the ambulance crew to our equipment, and delivered them to the patient, who was, indeed, mostly dead.
    in relatively rapid succession, we determined:
    A: the air ambulance could not fly due to not having sufficient visibility. (apparently they get nervous if they can't see all the way to the edge of their rotor disc)
    B: the patient had a chance if we moved it RIGHT NOW.
    C: the terrain was getting worse faster than it was getting better.
    so the patient was evacuated in the back of a four-wheel drive, and the unstoppable equipment followed in case the four wheel drive got stopped by the terrain. once we got to the road, the patient was moved into the ambulance, and was shipped off to the hospital. this would have been the end, for us, except that an inspection showed that some important stuff(tm) had been washed off of the equiipment, so I had to go back three days later, after the terrain had become passable, again. and search through the muddy water to find the stuff(tm) and one of the locals happened to mention, "oh, by the way, the patient... is coming home, tomorrow. just thought you should know."

    ReplyDelete
  2. Sad and frustrating case for you Doc. On a lighter note.The Trauma team who saved my nephew last Friday, he was stabbed 12 times, air lifted to the trauma team, got to see him walk out today. Chalk that one up to the win column!

    ReplyDelete
  3. What are your own thoughts on whether you would want to have the neurosurgeon do that hemicraniectomy on you? Would you be worried about severe disability?

    Just wondering on your own opinion ;)

    Thaink

    ReplyDelete
    Replies
    1. The options were A) no craniectomy with certain death, or B) craniectomy with probable death but possible recovery to some extent, and unlikely (but possible) full recovery.

      Delete
    2. it bears commenting that people have a tendency to forget dead is the default alternative to risky medical procedures.

      Delete
  4. I'm sorry, Doc. You all sure tried your damnedest, though!

    ReplyDelete
  5. There is pretry much always a chance, a faint hope when a patient arrives either mostly dead or dead and cold until there isn't.
    You did yor best and almost did a magnificent save.
    It was not to be this time, however in the future there may just be that one in a million save.
    Keep fighting the good fight Doc.xx

    ReplyDelete
  6. A: the air ambulance could not fly due to not having sufficient visibility. (apparently they get nervous if they can't see all the way to the edge of their rotor disc)

    Thank you Ken for the giggle at this comment. 

    ReplyDelete
    Replies
    1. I got my giggle when the chief ASKED if they would fly, because I already knew the answer.

      Delete
  7. I wish I could give you a hug somehow...you did your damnedest, and had it been possible for him to be saved, you would have done it, but unfortunately it was only possible to postpone the inevitable. Did any of his loved ones at least have the chance to see him and say goodbye? If nothing else, perhaps you were at least able to give them that much--I know it's not as good as actually saving him would have been, but I'm sure it meant a lot to them.

    ReplyDelete
  8. Wait, Doc, you lost me! You & your team managed to revive a guy whose heart had basically stopped, allowing no bloodflow to the brain. FOR 30 MIN. Add 2 days later, he opened his eyes! Then you did a CT a saw: "ischaemic damage to his entire cerebellum... with extensive edema to the point where his brain was starting to push his brainstem down into his foramen magnum". No heartbeat means no bloodflow & there was no head trauma, right? So what caused the brain swelling? That's what ultimately killed him, moreso than the stab wound, yes?

    I'm sorry that you lost him. But because of the engaging way in which you told that story, we all know that you & your colleagues did your very best to save Dale. And I learned a new medical phrase: "you're not dead until you're warm and dead", which I hope will never be of any practical use for me.

    You really oughta write that book, Doc.

    ReplyDelete
    Replies
    1. I'm not a medic but I think the swelling is due to the oxygen-starvation damage to the brain. As tissue dies it causes inflammation in what is left (at least it does in the main body - the brain is weird) and I suppose that causes the swelling.

      My guess would be that there was enough brain function left for him to open his eyes until the swelling essentially strangled what remained due to inflammation.

      Doc: Dammit!!

      Ugi

      Delete
    2. actually, "you're not dead until you're warm and dead" is not 100% universal.

      "cold, stiff, and displaying lividity" qualifies as Obvious Signs of Death(tm)

      Delete
    3. Unless you are a really shy and easily embarrassed corpse or really angry that you are dead :)

      Delete

If you post spam or advertisements, I will hunt you down and eliminate you.

Comments may be moderated. Trolls will be deleted, and off-topic comments will not be approved.

Web-hosted images may be included thusly: [im]image url here[/im]. Maybe. I'm testing it.