I've said it before, but I'll say it again: trauma is usually boring. I know, I make it sound so utterly fascinating here. I mean, if trauma is so devoid of excitement, why do I do it, and even more importantly, why the hell are you people here to share in my banality?
But it is sadly true: the car accidents, elderly falls, and bicycle accidents are just not typically exciting. Sure they may have some serious injuries, but there are only but so many broken ankles and concussions I can see before I feel ready to pack up and go home. Even the penetrating injuries often fail to inspire my intellectual curiosity. Indeed, most stabbings are mere flesh wounds. When I see a stab to the chest in a man who is awake and talking to me, chances are the knife just went into his chest wall, the bleeding is just from the underlying soft tissue, and a few sutures or staples are all that is necessary to staunch the not-really-exsanguination.
Until it isn’t.
Troy (not his real name™) decided that it would be a great idea to take some PCP before engaging in a high stakes poker match. This may not sound like a very bright idea, but that’s only because it isn’t. While I highly doubt Troy’s poker skills were scintillating while sober, they took a noticeable dive after the PCP, probably because he couldn’t tell an ace from a potato. After he lost everything including his shirt (literally (yes really)), the drugs told Troy that the only reasonable thing to do would be to demand his money (and his shirt) back in a language only he could understand. They guy who won both Troy's shirt and money fair and square said no (or something very closely approximating "no"), so Troy and his addled brain said something incomprehensible and then lunged at him. And the other guy predictably whipped out a knife and stabbed him in the chest.
Troy was brought to me in a still-incomprehensible mass of outrage and paranoia, bleeding very mildly from his chest.
“Hey Doc, this is Troy, 26, healthy. Two small stab wounds in the right chest. Vitals have been good, a bit tachycardic, breath sounds are equal. We put some occlusive dressings over the wounds, but they look pretty small and superficial.”
His vital signs were normal other than a slightly high heart rate of 100 which could easily be explained by the PCP, and he indeed had two small stab wounds, about 1 cm each, in his right chest over his pectoralis muscle, neither of which was actively bleeding. I started to assume that this would be just another “staple and go” stabbing victim, but my Inner Pessimist, on the other hand, wouldn’t let me assume anything and began whispering his usual obnoxious sweet nothings in my ear:
He's awfully thin, and you don't know how big the knife was. Maybe it went into his lung. Or his heart. Or his aorta. Maybe he's bleeding to death and YOU JUST DON'T KNOW.
But sure enough a few minutes later a chest X-ray showed a haemothorax, a collection of blood in the thoracic cavity.
I hate when my Inner Pessimist is right.
I inserted a chest tube which drained about 800 ml of dark blood, indicating that the bleeding was not from an arterial source, which you can probably imagine would be a Very Bad Thing. The treatment for a simple haemothorax is chest tube drainage for a few days, at which point the tube comes out and the patient goes home. Another patient saved. Huzzah, or something.
But my Inner Pessimist kept pestering me. What about the heart? Maybe it hit his heart! Look at the heart!
What are the odds, I was thinking. But making assumptions in my line of work is both a very bad diagnostic and therapeutic technique. So I did a bedside ultrasound on his heart and found once again that my Inner Pessimist was right - there was fluid in his pericardium, the sac that surrounds the heart.
Have I mentioned that I hate when my Inner Pessimist is right?
Fluid in the pericardium can be benign in someone with congestive heart failure, but fluid in the pericardium in someone who has been stabbed in the chest is unquestionably a Very Bad Thing. That fluid is blood until proven otherwise, because it means there’s a hole in the heart allowing that blood to escape and collect around the heart. Given enough volume, that fluid can compress the heart and not allow it to function properly, causing tamponade and death. And death is a Very Bad Thing.
What it truly means is I need to fix that goddamned hole. Most people with holes in their heart are either dead or actively dying, and Troy was neither.
Ten minutes later we were in the operating theatre, and five minutes after that I was using a very fancy saw to cut down Troy’s sternum. As the saw was doing its job, the slightly larger of the two wounds in his right chest started bleeding bright red blood. A lot. Now he was actively dying.
One of my assistants put her finger in the hole to try to slow the bleeding as the anaesthesiologist started pouring blood into Troy from above. I got his chest open and found about half his blood volume, now bright red, in his right chest. I opened his pericardium and found a very small hole, perhaps 3 or 4 mm, in his right atrium which I quickly repaired. It was clear, however, that was not where this bright red blood was coming from, as the blood in the right heart is deoxygenated and much darker, and the blood kept coming even with the heart repaired.
Hmmmmmmmmmmmmm. . .
A cursory evaluation of the right hemithorax showed that there were no injuries to the great vessels or the hilum of the lung. Well that's all fine and dandy, but that bright red blood was coming from somewhere in there. A closer inspection of the underside of the chest wall, however, showed that the knife had completely transected the internal mammary artery, which had clotted off initially but then started bleeding profusely once his blood pressure increased.
It took about 75 seconds to get that under control and then ligate it. We all then paused to take a breath and take notice of the complete lack of any further bleeding from anywhere. After the fact it all seemed rather trivial, though everyone in the room knew it was nothing of the sort. We all high-fived (not really), I cleaned him up, put in a bunch of tubes, and closed.
The next morning Troy was extubated in the intensive care unit, his haematocrit was rock stable, he was awake alert and talking, and he was shockingly unappreciative of our efforts at saving his life. He had two chest tubes draining the minimal residual blood from his right chest and another drainage catheter coming out of the middle of his chest which we had left in the mediastinum over his heart. I was rather stunned to see him looking so stable after everything that had happened, and after explaining his injuries and what we did for him, I asked him how he was feeling. Without missing a beat (and without answering the question), he demanded, “I need to go home today.”
“Um, no. No you don't. You just had open heart surgery less than 12 hours ago. You understand that, right?”
“But I need to get home to pick up a cheque. I have to go.”
No you don’t. I assumed he needed that money to pay off a gambling debt, but regardless I tried to explain that someone else would have to pick up his cheque. Troy was rather insistent that he had to leave. Unfortunately for him I was even more insistent that he stay.
Troy spent four contentious days in hospital with me, every day asking if he could go home irrespective of the number of tubes hanging out of his body (“I can come back to your office so you can remove it.”) and his inability to complete the most basic of self-care tasks, like walking and peeing. Finally the day of his discharge came, and even up until the moment he left he remained completely, utterly, and in all other ways devoid of any appreciation for what my team and I did for him, never once offering even the briefest of thanks for saving his life.
What did not shock me, however, is that he failed to return for any follow up. It’s been months, and Troy is either doing great or he’s dead, quite possibly of another knife wound. I guess I’ll never know.
Stories about general surgery, trauma surgery, dumb patients, dumb doctors, and dumb shit from the dumb world around us.
Thursday, 7 November 2019
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Someone being ungrateful to doc for saving his life?ReplyDelete
Surely you jest?
What did not shock me, however, is that he failed to return for any follow up. It’s been months, and Troy is either doing great or he’s dead, quite possibly of another knife wound. I guess I’ll never know.ReplyDelete
Which knowing you , means he will turn up sometime next week in a similar state.
What does your inner pessimist have to say?
I am always delighted when i get the notification you have made a new post.
It makes my day xx
I'm sure his stay in the hospital was marred by the fact you wouldn't serve him any PCP.ReplyDelete
Doc, I'd started to think the blog was over. I'm really, honestly happy it's not. I started reading since a few years back when I saw you on FML and it never ceases to quench my unquenchable curiosity. Thanks to you, I now know a lot of things which make my mother go "how do you know that?" Thanks doc.ReplyDelete
Not the point of the entry, i know, but an excellent piece of medical care.ReplyDelete
I've often wondered with procedures like this Doc': What happens to the tissues that were previously reliant on that artery for their blood supply?ReplyDelete
I realise that nearly anything is better than bleeding to death so I'm in no way questioning the need to do this. I just wonder whether ligating a vessel that can supply half the man's blood volume in a few minutes causes a load of down-stream tissues to die or at least struggle for a while.
Whatever the answer, still a great save!