Wednesday, 12 June 2019

Magic bullet

Before you start composing an angry comment over this blog post which seems to be about a blender endorsed by infamous charlatan and overall anti-science fuckwit David "Avocado" Wolfe, this is not about the Magic Bullet blender. Nor is it about this Magic Bullet (warning: link very NSFW). Nor is it about the JFK assassination or the Seinfeld parody thereof.

No, it is about an actually really real magic bullet that struck Belle (not her real name™). So delete your nastygram, sit back down, and stay tuned.

Let me first take you back a couple of weeks before I met Belle. My previous call before Belle's I had gotten a stabbing victim at 8 PM who needed a laparotomy. The call before that I got a car accident victim at 7:30 PM who needed a laparotomy. The call before that I had gotten a fall victim at 7:45 PM who had needed a laparotomy. Cases like these are relatively rare, so getting three in a row at essentially the same time of day is extremely uncommon. But as we all know, bad things tend to happen in threes. Or fours.

Yes, that's foreshadowing.

Now fast forward back (forward?) to the present. I was in the midst of getting over a cold, so I started my day by nearly begging the Call Gods to let me off easy. In retrospect this was a Very Bad Idea. About halfway through the shift the Call Gods proved that not only are they evil and vengeful, but they are also cold and heartless and have no goddamned regard for my feelings. Not that I ever suspected they did.

My pager told me I would be getting a level 1 gunshot victim in 5 minutes. I looked at the clock, and when I saw it was 7:50 PM, I actually looked up at the sky (because somehow in that moment I figured that's where the Call Gods were hanging out and laughing their cruel, heartless asses off) and vigorously and repeatedly cursed them with every single bit of foul language my brain could come up with. Then I took a deep breath and realised I had a job to do, and imprecating some nebulous nefarious fantasy creatures would help neither me nor my patient in the slightest.

Sigh . . . yet another call where I'll be in the operating theatre at 9 PM, I thought.  At least it isn't 2 AM, right?

Belle arrived a few minutes later, and while she didn't necessarily look close to death, she was certainly having some difficulty breathing.

"Hi Doc, 29 year old woman, single gee-ess-double-you to the right back. Blood pressure has been stable, oxygen sats in the 90's, but decreased breath sounds on the right."

My initial evaluation lined up perfectly with theirs - she had a single gunshot wound to the right mid-back with no exit wound. This bodes poorly because I have no idea what direction the bullet was traveling when it hit her or what happened to it once it did. On examination her heart sounded fine, but she had no breath sounds on the right, a sign that she had either a pneumothorax (collapsed lung), haemothorax (blood in the thoracic cavity), or both. Fortunately the treatment of both of these problems is the same - a chest tube. But whenever there is an entry wound with no exit, the main two questions I always have to answer are:
  1. Where did the bullet go?
  2. What did that bullet go through?
The good news is a simple chest X-ray should answer both of those questions within a minute or so. As the nurses were getting IV's started and checking vital signs (which were fine), I was finishing the physical exam (which revealed no exit wound and was also otherwise fine) and the radiology techs got the chest X-ray done. Within a minute I was looking at exactly what I did NOT want to see:

The bullet was overlying the left upper abdomen.

GOD DAMN IT. FUCK YOU, CALL GODS. FUCK YOU TO WHATEVER HELL I CHOOSE TO BELIEVE IN RIGHT NOW.

There are a lot of Very Important Structures between the right mid-back and the left upper abdomen, not the least of which are the right lung, heart, aorta and other great vessels, œsophagus, stomach, liver, duodenum, pancreas, spleen, and diaphragm. Holes in any of those things are by definition Very Bad Things, and holes in a few of them can be rapidly fatal, though obviously she shouldn't have any of those.

Maybe. Probably. At least she wasn't dead yet.

The problem is that an X-ray can't tell me if the bullet is in the soft tissue of the back (which would be fine), the soft tissue of the front (which would be much less fine, since it had to go through the entire body to get there), or somewhere in between (which would also be not at all fine), nor can it tell me what the bullet went through to get there. If the bullet was just in the soft tissue of the back, all she would need is a chest tube and no major abdominal or thoracic surgery. But you've already seen me foreshadow, so you know goddamned well that's not what happened.

A chest tube was rapidly inserted, and about 600 ml of blood drained immediately then stopped. While this sounds pretty bad, that's actually not a huge amount, and the fact that it stopped means there was no active bleeding from the chest. Good. Since her blood pressure and heart rate had remained essentially normal, I had time to get a CT scan for further evaluation.

It didn't answer my questions, it only muddied the waters further.

Not Belle's abdomen
Th scan showed the bullet tract through the right back into the right chest, bouncing off a rib and shattering it, then ricocheting (I guess) towards the left side.  And there bullet was, sitting somewhere in the left upper abdomen (not the soft tissue in the back . . . god damn it) apparently in the space right between the spleen and the stomach.  There appeared to be a blush of contrast in the stomach indicating active bleeding within the stomach (which was of course full of food), which as you can imagine is indeed a Very Bad Thing.

Weeeeell, shit. To the theatre we go. Again.

It was 8:30 PM. Because of course it was.

I re-examined her after the scan and just before wheeling her to surgery, and indeed her left upper abdomen was now mildly tender. Certainly no signs of peritonitis (yet), but the exam was decidedly different than it had been just a few minutes before. I told her she needed emergent surgery to find out what damage the bullet had done, and then (hopefully) fix it. As I listed off the potentially injured organs, I gave her no guarantee that she would survive the surgery just like I do with every such patient, because no matter what I suspect and no matter what I find, it is always both a challenge and a surprise. Belle seemed to take the news well: "Just do the best you can, doctor" was all she said.

I promised her nothing more and nothing less than that. And while I did get a surprise, it was just not the one I could have anticipated:

Nothing.

I found absolutely nothing. I was expecting to find a hole in her stomach with spilled gastric contents, a diaphragm laceration, liver laceration, lacerated intestine, perhaps a lacerated spleen.  But there was no blood in her abdomen, no spillage of food, no injury to any organ whatsoever.  NOTHING.

Well, almost nothing.  I did find one thing.

Knowing the bullet was somewhere in her left upper abdomen, I reached up into that area expecting to find a free-floating bullet between her stomach and spleen like I saw on the CT. I found the bullet alright, and it was indeed free-floating. In her stomach.

IN HER STOMACH.

Wait, what?? How the fuck did that get there? There are only three possible mechanisms for a bullet to get into the stomach:
  1. swallow it,
  2. go through the stomach wall, or
  3. go through the œsophagus and drop in.
Hmm.

I made a small incision in her stomach to retrieve the bullet, which was deformed from having passed through soft tissue (and bouncing off a rib), so option 1 was definitely out. I searched for at least an hour trying to find a hole in the stomach, looking at every square millimetre of its surface, both back and front, top and bottom. Nothing. So option 2 was out. That only left option 3 - through the thoracic œsophagus with the bullet simply dropping into her stomach.  But that would mean the bullet would have had to have juuuust enough energy to get in one wall of the œsophagus, stop, and then fall.

I wasn't buying it, but I had absolutely no other ideas. I took one last look at the stomach wall, but I once again came up empty. Since she had a nasogastric tube traversing the supposed area of injury in the œsophagus, I decided to close her abdomen and look for the injury another way.

My first study immediately after surgery was a CT œsophagram. Contrast was instilled into her œsophagus, and as the scan was done I should be able to see the leaked contrast, showing me exactly at what level the injury was. NOPE. That study, just like her surgery, was completely normal. NORMAL! Usually I want normal studies, but in this case I just wanted to find the goddamned hole.

Hmmm.

The next morning Belle was doing fine, awake, talking, minimal abdominal pain from her incision. Still no signs of peritonitis (or pleuritis, for that matter), and no further bleeding from her chest tube. She was very understanding as I explained how I was still trying to find how the hell this bullet got into her stomach, and that the next test would be an upper endoscopy. Later that day the endoscopist looked at every square centimetre of the inside of both her œsophagus and stomach. NOTHING. No blood, no injury, no hole. Nothing. NOTHING!

Hmmmmmm.

There had to be a hole there!  Where the hell is the goddamned hole?

My final study, my last chance, was a swallow study under fluoroscopy. Belle swallowed oral contrast and the radiologist watched it under real-time fluoroscopy. THAT will definitely show me the site of the injury leaing. It will show the injury, right? RIGHT??

Nope.  It was normal. Negative. Nothing. There was no hole anywhere.

FUCKING HMMMMMMMMMMMMMMMMMMMM

Over the next 4 days Belle had what I can only call a completely normal recovery from a completely abnormal surgery (her chest tube was removed on day 3). By her fifth day in hospital, she had essentially no pain, she was eating, she was pooping, she was walking, and she was ready to go home.

I saw her back in my office a week later, and she was continuing her totally normal recovery. I tried (and probably failed) to explain how bizarre a situation this was, and that she was a once-in-a-career type of patient.  Sure I've seen other patients who probably should have sustained some kind of damage based on their mechanism of injury but didn't, but never something like this. And I probably never will again.

Belle just laughed and said "Thank you for saving my life."

I was not and still am not sure I saved anything (except maybe her lung).

I have presented this case to literally every other trauma surgeon at my hospital, a few trauma surgeons from other hospitals, a few trauma surgeons from other countries, and DadBastard (who you may remember was a general surgeon for several decades). Not a single one has been able to offer me any insight as to how the FUCK this actually happened other than "Well, I guess it was a magic bullet".

So I offer it to you folks.  HOW THE HELL DID THIS HAPPEN?

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