I was on call last week at the Dartmouth Hitchcock Med. Ctr., the academic center of the Dartmouth med school and the only level 1 trauma center in region between Boston and Burlington VT. Generally, surgery call consists of trying to steal snippets of sleep next to a half eaten sandwich and a never-opened textbook, being paged intermittently to the emergency room for traumas arriving by ambulance or helicopter. Usually the page precedes the trauma arrival by 15-45 minutes depending on the situation, giving the pagees time to make their way to the trauma bay and 'suit up', which entails pulling on layers of lead aprons, impermeable gowns, gloves, face masks and hoods while readying fluids, medications, and imaging equipment. This happens for every trauma of a sufficient urgency, regardless of the patient's condition. So sometimes I will wait in a crowded room sweating, only to have a completely conscious (usually drunk) guy with a bruised head yelling about why he shouldn't be here as he vomits on everyone. Cases like this are anticlimactic and frustrating, not that I'm angling for people to be obliterated by motor vehicles, but if I'm going to lose an hour of sleep I'd like to at least learn (or suture) something.
So the other night, after a couple of these pukey/boozy dudes, I arrived a bit late to a trauma page and since the room was nearly full, took the advice of my intern and went to see a patient in the walk-in side of the ED for a suspected hernia. After examining this patient I returned to the workroom next to the trauma bay, which was oddly silent and empty. I didn't make anything of this until I noticed that my resident's coat, and face, shoes, and floor beneath the shoes were covered in flecks, and spots, and splashes of cartoonishly red blood. As I was processing this image, she put her hand on my shoulder and said, "GO TO THE O.R., WE CRACKED A GUY'S CHEST IN THE TRAUMA BAY. RUN." And so I took off at a dead sprint through the ER, up the stairs into the operating suite, pulling on a mask and following the ever widening path of maraschino cherry-red blood into the last and largest OR in the hospital. The operating table looked more like a meat counter than anything else, with intestines like link sausages being efficiently parsed and bundled over a moist quivering mass of shuddering human meat. As I put on gloves, I was told that the patient had apparently been struck by a car and found unresponsive by the ambulance crew. His blood pressure had bottomed out once in the helicopter and again in the ER, necessitating the opening of his chest like an old dictionary to look for an obvious and easily reversible cause of bleeding. When none was found, the surgeon took hist fist and jammed it into the man's torso until his aorta, a blood vessel the size of most household pipes, was compressed against the spine- maximizing the blood flow to the brain at the expense of the (relatively) expendable lower half of the body, as they sprinted his gurney into the elevator for emergency surgery.
Now, aside from the excitement of the sheer brutality and turmoil of the events, for the medical people involved in a situation like this there exists an additional sub current of tension- namely the knowledge that an open thoracotomy in a blunt trauma situation (like this one) carries a >95% mortality rate. With a steady stream of arterial spray escaping the left lung, the trauma surgeon and chief resident took turns compressing the aorta was the other gowned and gloved. After the first few minutes they signaled for me and my classmate to scrub in to help hold the organs and steel retractors as they searched for controllable sources of bleeding.
I stepped in, my waist against the open right chest wall, wielding the hand suction as the chief resident stapled off a mangled chunk of lung and systematically inspected the surfaces of the heart and chest wall for pulsing arteries. Once the spurting from the lung was resolved, and the heart itself cleared of punctures, he dove his fingertips into the constantly filling crater-lake of blood between the heart and left lung as I tried to clear his view by holding back the beating heart while applying suction. For the next 15 minutes we grappled to tie off the internal mammary artery, famous for it's use as in Coronary Artery Bypass Grafting, or CABG, which had been transected when the man's chest was ripped open. Apparently this vessel the size of the small end of a chopstick, has a nasty habit of withdrawing into the sternum when cut, which with the poor view afforded by the angle and blood and swelling organs, made controlling it a small nightmare. It was my job to suction away the blood while retracting the heart as the chief swung an inch long curved needle, almost blindly, toward the spastically hyperdynamic heart. This required a tiny, frenetic and intricately timed dance, darting the suction tip in front of the needle just as the heart squeezed and the lungs fell with exhalation, lingering just enough to remove the blood without obstructing the brief window of visibility that would allow the vessel to be grasped and oversewn. After several failed attempts and an ever alarming amount of pressure being applied to man's already overburdened heart, we suceeded in controlling the bleeding just as the cardiothoracic surgeon arrived to transition the operation from damage control to reconstruction.
I stepped out, put my hands on my knees and nearly passed out. As I stood and began to pace to shrug off the feeling of being deep underwater, my pager went off calling me back to the ER for another trauma...
