Superman

This is a crazy case that I ran across last week.  This guy was being robbed and was shot in the face at close range.  He put his right hand up in defense as the gun went off.  As is usually the case with bullets, your hand is not the best defense.  The bullet went through and through his right hand and then into his face via his right upper lip.  His hand was fine, no broken bones and completely neurovascularly intact.

As you can see by the facial x-ray, the bullet knocked out some of his teeth on its way through his oral cavity, somehow missing his tongue completely.  There was no exit wound on the other side of his face.

He also had a gunshot wound to his abdomen for which we had to take him to the operating theatre for an emergency laparotomy.  He had 12 holes in his small bowel from the bullet that went though his abdomen and we were able to resect the entire damaged portion of intestine in one piece and do a primary anastamosis.  Sometimes this is much better than fixing all of the individual holes as long as the section you have to take out isn’t too big.  It’s better to have one single suture line than 12 separate repairs.  There is a substantially smaller chance of having a leak postoperatively that way.

He did well after the case and was transferred to the ward for routine postoperative care.  The following morning on rounds, he surprised us all.  He spit the bullet out of his mouth!!!  I’ve only seen something like that in movies, never in real life.  It had been lodged in his left cheek and when he woke up from the anesthetic, he was able to spit it out.  Incredible.

Another crazy Saturday in Cape Town

My first big call as a consultant came last Saturday.  It was the perfect storm.  I walked into morning rounds and found a patient that had been stabbed in the heart.  He was hypotensive and bleeding out of his left chest.  His neck veins were distended, which is a sign of cardiac tamponade (were the blood from the lacerated heart compresses the chambers from the outside and doesn’t let the heart fill up properly).  We took him to theatre immediately and did a sternotomy.  When we opened his chest, we found a huge clot of blood around the heart and a stab wound in the left ventricle.  We had to pick up the heart to fix the wound, and every time we lifted the heart up, his blood pressure would drop.  So we did one suture at a time giving his heart a chance to recover between manipulations.  His blood pressure improved dramatically when we were done.  He had a hole in the left lower lobe of his lung from the knife tract, so we did a wedge resection old school style.  We didn’t use staplers, so we clamped and oversewed with monofilament suture.  He was stable after the case, but we sent him to the ICU for monitoring.  That was the first case of the day.

The next case was a pedestrian that was hit by a car.  His left elbow was shredded and there were chunks of his bone missing.  The CT scan of his abdomen showed free air, so we opened up his abdomen simultaneously as the orthopedic doctors were trying to clean out and re-approximate his left elbow.  His spleen and pancreas had lacerations, so we did a distal pancreatectomy and splenectomy.  Thankfully, he was very stable during and after the case, so he went to the ward afterwards.

The third case was a guy who got stabbed in his right arm and had an injury to his brachial artery.  There was a complete cutoff of flow in his brachial artery and he had a median nerve deficit in his right hand.  We took him to theatre and repaired the brachial with a primary anastamosis.  We cut out the injured piece and sewed the two healthy ends back together.  Feeling the pulse in his wrist at the end of the case is such a relief, I cannot begin to describe it to you.  We had the hand surgery come in afterwards and repair his median nerve.  Happily, he did very well and was miraculously able to move his hand without any difficulty the next day.

The fourth case was a guy that got shot in his left buttock.  The bullet entered about 2 centimeters from his anus and was lodged in the subcutaneous tissue in between his pelvis and belly button.  He had a catheter in his bladder and his urine was stained red from blood.  We did a rectal exam and found blood in his rectum as well.  That told us that the bullet had gone through his rectum and probably his bladder as well.  We were worried about the ureters, but knew that we would be able to see more once we established the bullet tract intraoperatively.  We opened his abdomen and found that the bullet had not entered the abdomen at all.  It was pristine.  There was however, a very large hematoma in his pelvis.  We opened up the bladder from the top and found two holes deep down in the nether regions of his bladder.  It was hard to even SEE them they were so deep.  I got between his legs and was working my hardest to retract with one hand whilst sewing with the other.  I was sweating so much during the procedure that one of the nurses needed to wipe my brow with gauze.  It’s hard work retracting and sewing some times!  I cannulated a pediatric feeding tube up his left ureter to make sure that when I closed the bullet holes, I wasn’t catching the ureter in my repair.  That’s something you never want to do.  The repair went well, and the ureters were flowing golden happiness when we closed the bladder.  We gave him a colostomy for his rectal injury and got him off the table.  He was stable and we were able to transfer him to the ward after the case.  As long as a rectal injury is outside of the abdomen, you can get away with diverting the fecal stream away from the injury, and it heals by itself almost every time.  We’ve learned that you don’t have to repair the injury itself because it is contained by all of the tissue around it.  The patients need a colostomy (which is never to be taken lightly), but it’s been proven to be much safer than going in and trying to fix those retroperitoneal injuries.  You can reverse the colostomy and restore their normal function 6 months later.  Surprisingly, some people don’t want their colostomies reversed.  If you have a curious mind and don’t mind being disgusted, I invite you to google “colostitute”.

While we were doing that case, two new customers arrived in the frontroom.  It was 4am.  One had a gunshot to his left back and the other had a stab wound to his abdomen.  We decided to take the gunshot victim first because he looked a lot worse than the other guy.  I explained what we were doing to the stabbed guy and he said “do what you gotta do, save the other guy”.  He was cool. 

We made the right choice.  When we opened the gunshot victim’s abdomen, he had a huge zone 1 hematoma (a collection of blood in the middle of the abdomen, usually a sign that a BIG vessel got hit).  Those are scary.  I knew we were in for BIG trouble.  I told the anesthetists to order extra blood and was preparing for the worst.  I got control of the aorta below the diaphragm just in case, and then went for the bleeding.  I had someone call downstairs and get another assistant to help with retraction because I knew we were going to need all the help we could get.  We did a right medial visceral rotation, where you dissect out and lift the entire right colon and the small bowel out of the abdomen.  It is an amazing exposure (check out the picture below).  But when we did that, dark blood started gushing out of the middle of his abdomen.  It is rare that you can actually hear bleeding.  It’s called “audible bleeding,” and tells you that you’re in for a hell of a ride.  It was coming from his vena cava, the biggest vein in the body.  I put my finger in the hole and the bleeding stopped.  I could feel where the bullet had ripped through his spine with my finger, which told me that the bullet had gone through and through the vena cava as well.  Not good.  Luckily, I have found that my finger is perfect for 9mm bullet holes.  It plugs them up without any leaking!  This became apparent to me on this case because my assistant’s hands are a full size smaller than mine.  When we traded, and she put her finger in the hole, blood was still gushing around it.  She had to use her thumb instead, which turned out to be equally effective.   After a long battle, we were able to get proximal and distal control of the vena cava, but it wasn’t easy.  The injury was just above the bifurcation, so I had to clamp off the common iliac veins individually.  The right common iliac artery was in the way, so we had to double sling it to get it out of the way (again, see the picture below).  There was also a pesky lumbar vein that was hosing blood that we finally tied off.  Once we got control of the bleeding, we were able to see that, in fact, the bullet had gone right through the back wall and the front wall of the vena cava.  I could’ve just tied off the entire vena cava and hoped for the best, but he was incredibly stable at this point.  We were able to control the bleeding with our fingers (and thumbs) and he had only lost 700 mL of blood during the case.  I decided to go for it and fix the vena cava.  I had to open up the anterior bullet wound to get to the posterior one.  Once I cleaned up the eges, I repaired the back wall from within the vena cava. 

When that was done, I repaired the anterior defect.  We released the clamps and my sutures held.  It was awesome.  They were able to extubate him after the case and he was so stable that we were able to transfer him to the ward postoperatively.  No ICU bed needed!

It was an incredible 24 hours, and all of the patients we operated on were doing well the next morning.  We could have never succeeded if it wasn’t for the coordinated work of the entire team at the hospital.  We were a well-oiled machine that night.  Everyone was working together and we got some amazing results.   It reminds me of how lucky I am to have this job.

My biggest case so far

Let me just start by saying that I am very thankful that most of my trauma patients here in South Africa are very lean individuals.  It makes operating much easier.  The larger someone is (around the waist), the harder it is to operate on them.  It is technically more difficult to get into the harder to reach spaces, and the anatomy is always obscured by the seemingly endless layers of fat.  It feels like a battle trying to hold the fat out of the way while you are trying to throw a stitch, or gain exposure to a certain area to stop the bleeding.  In the middle of the night, when we’re running on the skeleton crew, it is even more difficult.  Sometimes you need 2 or 3 assistants to help retract in order to get good exposure, but that’s a luxury in the middle of a busy night.  To top it off, bigger people usually have bigger complications.   Their bodies are already under a lot of strain, and when you add the hit of a big trauma, things tend to start falling apart.

That being said, most cases I can thankfully do with only one assistant.  Almost all of the trauma patients here are in good physical shape and don’t usually have too much body fat.  But as the saying goes, when it rains, it pours…

We had a fairly large gentleman come in with a gunshot that entered his body through his right chest.  The bullet was sitting right under the skin on the left side of his chest, you could feel it with your hands.  That’s usually bad.  Anytime a bullet crosses the midline of the body, you can be in BIG trouble.  To top it off, this guy was about 250 pounds.  I was most worried about his heart, because the bullet path looked like it went just underneath the heart.  He was hypotensive and a quick bedside ultrasound (aptly named the FAST exam) told me that he was bleeding into his belly.  I took him up to theatre as fast as I could.

I started with a subxyphoid window.  That’s when you make a midline incision in the upper abdomen and look at the heart through a small window in the pericardium to see if there is any injury to the heart.  It’s usually a pretty easy procedure, but not tonight.  I found my fingers and clamps swimming in a pool of fat.  I was trying to find the pericardium, but just couldn’t get to it.  I was asking my assistant to retract the sternum, but her arms were getting more and more tired.  I started sweating.  It was definitely the hardest subxyphoid window I had ever encountered.  It was 4am, and it was the beginning of the case.  Great.  After a prolonged struggle, I finally found it hiding out, up far beneath his sternum.  I opened up the sac and thankfully there was no blood around the heart.  Nice.

We closed that incision, and then dove into the abdomen.  He had a ton of blood, and we were able to trace the path of the bullet.  It had entered the right chest cracking his rib.  It had then gone through the lung and diaphragm and then into the liver.  It crossed through the entire liver, went through the stomach twice, and then went through the right diaphragm, the right lung and was sitting under the skin on the other side of his body.  He was lucky that it didn’t hit any of the major vascular structures.  Most of the blood had come from his liver.  We washed out the lungs, fixed all of the holes, left some drains, and removed the bullet.  I felt like I was fighting with this guy’s fat the entire case.  I only had one assistant and it was a struggle, but we did pretty well.  The rest of the case felt easy compared to the subxyphoid window!  I was able to close his abdomen and we arranged for an ICU bed.  Just as I was scrubbing out, my phone started ringing again.  There was a new patient in the frontroom with 3 gunshots to the abdomen.

I got out of the OR at around 6am.  I went downstairs and ran into one of the guys from the frontroom on my way to the resus bay.  He asked if I had seen the “big” patient.  I told him, yeah, I just operated on him and I think he’s going to be all right.  That’s when he said, “no not that guy, the BIG patient.”  I walked around the corner, and this is what I saw:

My heart sank.  It was as if I was being punished for complaining about the last guy.  This new guy had three gunshot wounds to the right side of his abdomen, he was hypotensive, and he weighed over 500 pounds.  We had to operate on him right away.

Now came the problem of his size.  He wouldn’t fit on a standard operating table.  No way.  There was a rumor that we had an extra large bed, but when they brought it down, I realized there was no way it was going to work.  It was a hospital bed, not an operating table.  I took a look at our options and decided to bring a second table into the operating room.  We put the two tables side by side and got the patient in the middle.   This arrangement wasn’t ideal either, but it was the best I could do.  The table was too wide, so in order to reach the patient, the people on the left side of the table had to operate on their knees!  Far from perfect, but we were out of other options.

After cutting through about a foot of fat tissue, we finally got into his abdomen.  I took one look in there and knew he was in Big Trouble.  One of the bullets had gone right through the head of the pancreas and had destroyed the second part of his duodenum (an area known as the “surgical soul”).  Wounds in this area are notoriously bad due to their complexity and the complications that patients have postoperatively.  His entire right colon was also shredded by another bullet.  He was unstable (requiring adrenaline in order to keep his blood pressure up), so I was operating in “damage control” mode.  I took out the right colon as fast as I could, leaving his GI tract in discontinuity.  We then cobbled together his duodenum and got out of his abdomen as quick as possible.  When someone is unstable and requires blood pressure support like this guy did, the best operation is usually the quickest operation.  You have to stop the bleeding and contamination and then get out, so that the patient can be properly resuscitated in the ICU.  If you take to long on the operating table, they usually die.  We put a vacuum pack on his abdomen and got him off the table (with a lot of help) as soon as we could.

Unfortunately, the trauma was too much for his body to handle.  He never stabilized.  He was in septic shock and we were never able to pull him out of it.  He died early the next morning in the ICU.

The first patient didn’t have an easy post-operative course either.  He was also in septic shock and was in the ICU for an entire week.  He had a wound complication, but he finally pulled through and we discharged him a few days ago.  He walked out of the hospital.

Happiest guy... with a knife in his neck

This is the happiest guy I have ever seen with a knife in his neck.  Hands down.  He came in with completely stable vital signs.  He had no neurological deficits and he was only in a little bit of pain.  It was quite remarkable.  The knife was stuck so deep that the assailant couldn't pull it out.  We got a CTA of his neck (that's a special cat scan where we inject die into the patient's veins right when the scan is being taken.  That shows us all of the important blood vessels so that you can see if any of the critical vessels are injured before you just go diving in).  The CTA showed that the knife was imbedded in his clavicle on the opposite side.  It missed all of his important vascular structures.  Lucky for him, it also missed his trachea.  We took him to the operating room thinking it was going to be easy to pull it out, but we got a little surprise.  It was stuck into his clavicle like the sword in the stone.  I was pulling so hard on it that it literally lifted his shoulders off the operating table.  Then I wisened up and grabbed his clavicle with one hand and wiggled the knife out with the other.  You're really not supposed to wiggle knives out because you might cause more damage, but I had seen the CTA and knew that it wasn't sitting close enough to anything too important.  Once it finally came out, I breathed a sigh of relief, and blood started oozing out of the wound.  Thank goodness blood wasn't spurting out.  I had made a good choice.  We then had to explore the wound to tie off the bleeding vessels.  It turns out, the knife went through both of his anterior jugular veins.  We got control of those pretty easily and the guy walked out of the hospital 2 days later.  He was still smiling.

This guy, on the other hand, wasn't so happy:

His knife was going through his forehead and sinuses, through his hard palate and into his mouth.  Again, rock stable vitals, but a knife sitting in a very precarious location.  Every time he tried to close his mouth the tip of the knife poked his tongue.  He was not a happy camper.  Definitely not smiling like the last guy.  The x-ray we got shows the trajectory of the blade.  It's obvious that the guy who did this to him meant business.  He put so much force into stabbing this guy's face that he BENT the blade.  Amazing.  Believe it or not, this guy did pretty well too.

Man vs. Truck follow-up

Man vs. Truck follow-up

I thought it would be nice for you to see some follow-up pictures of the guy who had the degloving injury of his left leg and scrotum.  This first photo is what his leg looked like right before we grafted it. 

That beefy red tissue is called granulation tissue, and that is what you want to see before you put a skin graft on.  The granulation tissue has good vascularization and is optimal for supporting a skin graft.  We sent a swab of the exposed tissue to microbiology to make sure there weren’t any nasty bacteria living there before we did any grafting.  A hefty bacteria load will sabotage your graft from the get-go.  When that came back negative, we took very thin (1 millimeter thick) strips of skin from his opposite leg and put them through a meshing machine to make them look more like a piecrust.  This allows the strips of skin to cover more surface area and also lets fluid escape from underneath the graft, keeping it well opposed to the tissue below.  We then cut the strips to fit the defect, and stapled them onto the healthy granulation tissue.  It’s kind of like arts and crafts day in the operating room.  I usually enjoy doing skin grafts.  It’s a fun project that is very satisfying when done well.  Finally, we place a vacuum dressing on it and cross our fingers for the next 5 days.  The vacuum dressing is basically a big sponge that is hooked to a negative pressure device.  This helps whisk away the fluid and also keeps the skin graft firmly pressed against the granulation tissue so that it starts using the blood supply from the tissue below to grow.  It is truly amazing what the body is able to do.  The skin is able to get blood from the granulation tissue and form new blood vessels through a process called angiogenesis.  All we have to do is slap some skin onto healthy tissue and the body does the rest.  It’s awesome to see it work.

This is a picture taken 2 minutes after we removed his dressings for the first time.  I know it probably doesn’t look that good to you, but it looked absolutely fantastic to me.  Almost 100% of the skin we grafted had survived and was doing well in its new locale.  When his pelvic fractures heal enough for him to support his weight, he will be able to walk again.  His leg is saved.

And his left testicle survived as well :)

Man vs. Truck

First of all, I want to apologize for not putting up any new blogs for a while.  It has been CRAZY at work lately, and I just moved into a new place two weeks ago.  I really like my new place.  It's super homey and has a fireplace.  I'm in my own private cottage in the back yard.  It's perfect.  The weather is starting to get cold and wet here, but I guess what goes around comes around.  I had summer for Christmas after all.  As winter is taking its grip on the CPT, I am still amazed at how many people get shot and stabbed on these cold, rainy days.  I’ll post some of those stories next week.  What we are definitely seeing a lot more of right now is car accidents.  Here's what happened to a guy last week:

This unlucky gentleman was hit and dragged by a truck.  When I say gentleman, I really mean it.  He is one of the nicest patients I have had here.  He had the unfortunate experience of finding himself underneath a truck, fully conscious and bleeding to death.  He had a pelvic fracture and a “degloving” injury of his Left leg.  If you haven’t heard of a degloving injury before, just imagine taking a glove off, but the glove is your skin.  Yep, not really what you’re looking for on a cold rainy day whilst crossing the road.

This degloving injury looked more like a picture from an anatomy textbook.  Almost all of this man’s leg muscles were exposed and could be seen very clearly.   His left testicle had been torn out of his scrotum as well.  Don’t worry, it was still alive and kicking, but had to be tucked back away into it’s furry home and pexied into place.  For those medical people out there, his inguinal canal was completely exposed as was his spermatic cord.  It was truly an amazing sight.  You could put your finger right down into his broken pelvis through the floor of his inguinal canal.

We were able to re-approximate his skin and cover his entire leg and groin.  The skin flap was too big though.  Most of the small blood vessels that supply the skin had been torn off, and the skin at the edges were too far away from the feeding arteries to get enough blood to survive.  I had to take him back and debride the wound several days after his initial accident.   Now he has a skin defect that is about 15x24 inches.  We placed a vac dressing on it, and will perform a split thickness skin graft using skin from his other leg to cover the defect after his leg has a little more time to heal.

                Don't worry, we were able to save the scrotum.  I guess he's lucky after all, right?

Community Assault

Community Assault is a term that I had not heard of before coming to South Africa.  It turns out it is fairly commonplace here and deserves mentioning.  When someone in the community commits a crime, they are chased down in the streets and beaten (sometimes to death) by members of the community as a form of punishment.  This form of vigilantism has its roots in the Apartheid era when the South African police force was focused on repression instead of protection within the townships.  Those communities had to police themselves and take matters into their own hands.  This form of justice unfortunately has remained prevalent and has even been on the rise in certain areas in the past few years.  The “criminals” are beaten with various tools and weapons like sjambocks, spades, sticks, and sometimes machetes.  However, nothing is as bad as necklacing (a tire necklace filled with kerosene), being by far the official “worst way to die."  Ever.  

Most of the patients that make it to us have massive bruises covering their bodies.  We treat them all for potential crush injuries and check their urine specific gravity to make sure that the breakdown products from the soft tissue trauma are not clogging up their kidneys and forcing them into renal failure.  Most of the people that make it to us make through OK, but a few have died in our hands.  Usually they die from head injuries that are non-survivable, but sometimes the beatings are so bad that they die from other complications related to the severity of their “punishment.”

Here’s a picture of a young man that came in after being caught for stealing.  He did not have any broken bones, but you can see the extent to which he was beaten by the sjambocks.  His back was by far the worst.  This kid made it out OK.  His kidneys responded to our treatment and he was able to leave the hospital in a couple of days.