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.

Suicide Attempt

Despite this gentleman’s best effort (he made an incredibly good effort- in fact, the most impressive attempt at suicide that I’ve seen thus far), we were able to save his life.  It is rare to see someone try to commit suicide by slitting his or her own throat, but it is even more rare to have someone that tries this hard.  I am amazed that this guy lived.  The true hero in this case was the paramedic who was able to find his airway and place an endotracheal tube directly through the gaping hole in his neck into his windpipe.  If it wasn’t for him, this man surely would have died on the scene.

When he got to us, he had lost a fair amount of blood, but had a stable airway.  After resuscitating him in the frontroom, we took him to the OR and did a formal tracheostomy below his incision.  This allowed us full access to the injury.  I have never seen anything like it.  He had cut through and through his trachea.  It was completely transected.  Not only that, but his esophagus (behind the trachea) was transected as well.  This picture is a view that I had never seen before.  You can look directly down his windpipe from above:

The most incredible part about this is that he missed the major vascular structures in his neck.  I’m not sure how, but he didn’t hit either of his carotid arteries.  We repaired his esophagus and trachea that day in the OR and he did pretty well afterwards.   He was able to talk in a whisper 1 week after the injury, but he still has an esophageal leak.  He's alive, but definitely not back to normal.

The question I get most often about cases like this is "why would you save someone that wanted to die?".  A good question with a simple answer.  We don't care.  It is not our place to judge.  We just do our best to save lives and fix the problems that are presented to us.  The most interesting thing about attempted suicides is that most of the patients are very thankful after we save them.  I can't remember any person that was angry after we saved his or her life.  The guy in the pictures above was one of the better patients I've had a Groote Schuur.  He was very appreciative of what we did for him.  Even though his life actually got a lot worse and a lot more difficult after his injury, he was able to see that life is still worth living.  This to me is inspirational.  Just when you think that life can't get any worse, it sometimes does.  But life is the most precious gift, and we all know that deep down.  At the end of the day, be thankful for the things you have.  Be appreciative of how good you have it today, because you never know what tomorrow may bring.

My first solo call

I had my first solo call night last Saturday.  Oh yes, Saturday night, and I was alone.  I had been taking calls with the other “cutting registrars” for 3 weeks, so I knew more or less what to expect, but nothing can prepare you for a crazy night at Groote Schuur.

Right when I walked in the door, there was a guy that was unstable and needed to go to the Operating Theatre ASAP.  He had 4 gunshot wounds and 2 retained bullets.  One was sitting right below the zyphiod process (bottom of your sternum) and one in the pelvis.  He had blood in his belly and his blood pressure was too low, so I immediately took him to the OR.  No cup of coffee, no breakfast, straight to the OR.  Turns out he had 27 holes in his intestines that I could see.  There was one bullet hole in his rectum, and I had to assume that the bullet had come from the other side, which was extra peritoneal.  I did a mixture of primary repairs and 2 formal resections.  I left him with 200cm of small bowel (which is enough- 100 seems to be the magic number).  I also did a diverting colostomy to protect his rectal injury that I couldn’t get to.  It was a good operation and he did well. It took me 4 hours.  Yes, I will get faster.  Just give me a little time, OK?

Later that day I did a fasciotomy for a guy with bilateral femur fractures and a completely crushed ankle.  I’m already getting much more proficient with my fasciotomies.  It’s a very important operation, but it’s something I only did once during my entire surgical training in Santa Barbara!  Now I’ve done 3.

Later that night is when it started to get really interesting.  I had a 74 year old man who was stabbed in his forearm and had both his radial and ulnar arteries (the two main arteries in your forearm) severed.  He had a cold hand and no dopplerable pulses whatsoever.  He was pretty drunk, so couldn’t tell us the exact time he had been stabbed, but it was around 6 hours before he had come to us.  I had to get him to the OR ASAP or he could loose the function of his arm.  His hand was still motor/sensory intact though, so I knew I still had a little time to spare.

Ten minutes later, a 24 year old guy came in who had been stabbed in the left flank and eviscerated earlier that night.  For better of for worse, he was treated at an outside hospital before coming to us.  There was a note that accompanied the patient (not unlike 2^nd grade when teachers used to pin notes to the kids) from the outside hospital, and it said “multiple loops of small bowel and colon were protruding through the wound with obvious spillage of feces”.  Their response was to stick the bowel back into the abdomen and staple him shut.  I have NEVER seen that one before.  That violates several basic principles of surgery, but they didn’t have any surgeons at their hospital, so what else were they supposed to do?  The more I thought of it that night, the better an idea it seemed to me.  At least his bowels weren’t flapping in the breeze desiccating the whole time, right?

So I gotta make the call: old guy with the dying hand, or evisceration guy who is getting more and more feces in his abdomen by the minute.  I chose old guy.  But of course, both operating rooms were already full.  There was a marathon ortho case going (surprise) and an optho case with someone that had a foreign body in the globe of their eyeball.  So I had to wait.  I had a real bad feeling about waiting, but I didn’t have a choice.

Just when my waiting was up and they were putting the old guy onto the OR table, a new guy rolled into the Trauma bay.  We’ll call him “machete guy”.  This O (South African term for a guy) had been hacked at with a machete by someone who was not messing around.  Whomever it was meant business.  He had 3 huge gashes on his head that were down to the bone and I could feel and see fractured skull through the incisions.  Both of his hands were basically chopped off, and he had multiple large gashes over his torso and back.  He was in bad shape.  His blood pressure was 70/40 (too low) and he needed help fast.  It was at that moment that I had a realization: I was screwed.  I called the OR and told them to wait 5 minutes for me to make a decision.

I took a step back and evaluated machete guy.  We had put two chest tubes in him and he wasn’t bleeding from the chest.  I did and ultrasound and it didn’t look like he had any blood in his abdomen.  His heart looked good too.  I realized that his blood pressure was low from all the blood he had already lost.  All we had to do was resuscitate him and stop the bleeding from his open wounds.  All of this could be done in the trauma bay.  We gave him 4 units of warmed blood as fast as we could, and his blood pressure started to respond.  This let me off the hook for the time being.

I ran up to the OR and did a vascular anastamosis of the old guy’s severed radial artery.  Got a pulse back and his hand warmed up in the OR.  It was good.

Then I checked on machete guy and he was still doing OK, his vitals had stabilized and the students that were on that night had sewn up all of his lacerations.  He still didn’t NEED the OR, so I took stab wound evisceration guy to the OR and fixed the 4 holes I found in his gut.  I was able to close him and he did pretty well throughout the case.  By the time I finished with him, it was 9am.  My shift was done.  What a rollercoaster ride.

I was so busy that I didn’t get the chance to take any pictures that night.  Sorry.  Here’s one from the next morning right before I left the hospital.  Still had a little blood on my scrubs, but that’s becoming par for the course.

Yes, it is Mustache March after all

3 Nights: 3 Knives to the spinal column

It seems we were running a special on knives in the spinal column a few weeks ago.  First, we had a guy that had a knife directly into his spinal cord at T3.  INTO HIS SPINAL CORD (that deserves repeating by the way).  The amazing thing about this guy was that he only had a small sensory deficit in his right leg.  Otherwise he was completely fine.  Still walking.

The next night, we had this guy come in (yes, different patient, different knife):

It's interesting that the first two knives didn’t have their handles on them anymore.  I guess they just don’t make ‘em like they used to.  Apparently, wedging knives into the spine produces enough force to break off the handles of these second rate knives.  They’re definitely not Cutco quality.  Check out the x-ray and 3D recon images:

I feel like I’ve come full circle, because a patient with a knife in his back 7 years ago in the Bronx is what lit my fire for trauma surgery in the first place (I’ll tell you that story in person if you haven’t heard it yet, it’s a good one).  If it wasn’t for knives in peoples’ backs, I woulnd’t be here right now!

The second guy got incredibly lucky as well.  As you can see from the CT scan, the tip of the knife was just lateral to his spinal cord, wedged in between the facets of C5/C6.  The blade was tickling his right vertebral artery but didn’t do any damage to it!  

We were able to pull this knife out under local anesthesia in the Emergency Department.  He didn’t even have to go to the OR!  We observed him overnight and he walked out of the hospital the next morning.  He has no idea just how lucky he was...

I always try to save the best for last.  This final guy’s knife still had the handle on it (obviously a better quality) and it was stuck into the side of his Left chest.  He came in walking and talking, and initially we had NO IDEA how deep this knife went in.  When we got the x-ray, we were all blown away:

I’ve never seen anything like this.  The guy was completely stable, but he won himself a left sided thoracotomy so that we could be prepared for the worst when we pulled it out.  Miraculously, it came right out without any problems.  He walked out of the hospital 2 days later!  The blade went right behind his aorta and stopped when it hit his spinal column.  A centimeter difference and he would have been dead.  Another lucky dude who probably has no idea how lucky he really is.  I'm learning that luck is a relative term here in Africa.

22 gunshot wounds and still alive

This morning at 3am they wheeled a guy in that had 22 gunshot wounds.  This guy puts 50 cent to shame.  When he came in, he was still able to tell me his name, but he really wasn't in the mood to tell me how it all happened.  All I knew was that he had lost about 2 liters of blood from his left chest and we had to move fast.  With that many gunshot wounds, it was tough to figure out the trajectory of all the bullets (which is important when you're planning an operation).  Luckily, we have a Lodox machine that can x-ray the entire body in about 13 seconds.  The Lodox was originally developed by South African diamond miners so that they could tell if any of the miners were stealing diamonds as they left the mines, but that's another story.

Here's a small piece of the Lodox:

After the Lodox, we still had a couple of mystery bullets.  There were 3 in the abdomen, and it looked like some had crossed the mediastinum (center of the chest) and diaphragm.  Any time you have bleeding in 2 body cavities, it can be BIG TROUBLE.  Opening the wrong body cavity first can be a fatal mistake.  We didn't have time to do a CT scan because he was too unstable.  He kept bleeding out of his chest and his oxygen saturation was falling.

We rushed him to the OR and opened the Left chest via an anterolateral thoracotomy.  Turns out it was the right move.  Two bullets had zinged through both lobes of his lungs, and he was pumping blood out of the holes.  One bullet was on it's way up to the neck and the other on it's way past the diaphragm and through the liver.  The bullet tracts in the lungs were too deep to staple off so we had to open up the tracts using a cool technique called a tractotomy.  You fire a stapler THROUGH the bullet hole and then deal with the leaks head on.  It worked like a charm.

Once we had the chest under control, we opened his abdomen and found a big gash in the liver, 14 holes in the small bowel, 2 at the terminal ileum and one in the pelvis right next to the rectum.  He had a  bullet lodged right next to his SMA (a very big and important artery for your intestines).  It was miraculous that no bullets hit any major vascular structures.  This guy must have taken some serious notes while watching the Matrix.

After anesthesia caught up and he stabilized, we had time to fix him properly.  We did 2 small bowel resections and an ileocecectomy (taking the terminal ileum and cecum), which took care of all the holes in the bowel.  We stopped the bleeding from the liver and we tied of his right Vas deferens that had been taken out by the pelvic bullet.  Don't worry, he still has an intact Vas on the left so he will be able to reproduce fine offspring one of these days.

The case took a little over 5 hours and we were able to close him up at the end.  It was amazing that he pulled through.  One bullet taking a 3 millimeter detour in the wrong direction would have been game over for this guy.  At the end of the case, he definitely looked worse for the wear, but he was still alive and in stable condition.  Once we stopped the bleeding in the chest, his hemodynamics improved like magic!  That's one of the things I love the most about trauma.  Healthy people in the wrong place at the wrong time.  You fix the holes in time, and they get better.  We left 2 chest tubes and 3 abdominal drains:

All in all, a pretty lucky dude.

...so am I.

A different kind of trauma...

We had an interesting case come in last night.  If you are over 18, and don't mind hearing about deviant behavior, keep on reading.  Otherwise, just close this window now and check again when I have my next post.

A young man was referred to the trauma department at 3am because his situation was becoming more traumatic by the minute.  He had put on a chrome cock ring at 3pm the day before, and after an enjoyable afternoon, found himself in the unfortunate position of not being able to take it off.  He "sat on it" for 10 hours before the pain became so intense that he had to come to the Emergency Department.  They didn't know how to get it off, so they referred him to Trauma.

Now, I left this picture intentionally blurry to protect the innocent.  You can see that the ring was placed over the entire package (not jus the shaft), which seems like a really bad idea to me from the get-go.  He was in excruciating pain and was willing to let us do anything to help.  That's definitely the head space you need to be in to allow us to attempt what you can see in the next picture...

We got out the 3 foot industrial bolt cutters and went to work.  Mind you, the ring was steel and in a particularly sensitive and important area.  It was not a simple or easy task to cut it off.  After multiple attempts and several rounds of patient analgesia we were finally able to get a good angle and cut through the ring.  Everyone in the room breathed a big sigh of relief, but no one was more relieved than our patient.  He was one of the most appreciative patients I have seen thus far.

My Registration: finally finalized!!!

After over a year of sending documents to South Africa, and 1 1/2 months of being here in person trying to get licensed to operate, it has finally arrived!  That was a long, expensive, tiring, redundant, frustrating experience, but it's good to know that they don't just let anyone come over and start cutting on people.  I will be working in the "Front Room" (which is basically two rooms that serve as the resuscitation bays) for the first 4 weeks, then I will start taking call and getting the trauma experience that I came here for.  I am happy that I've had some time to explore South Africa, but I'm more than ready to get to work.  Bring it ON!

My life in the CPT

Volunteering has its costs, and its benefits...

I started working on the paperwork to come out here over a year ago.  I submitted every form they asked me for and mailed it all over via courier as requested.  It was a very expensive and tiring process.  All in the name of volunteering.  Apparently the document proving that I had finished my internship at Cottage Hospital was lost in the shuffle AFTER it arrived here in Africa.  Someone signed for it, but it is nowhere to be found.  No one ever told me that this document was missing, and I came here thinking that everything was in order.  It took a full week to find out exactly what was holding my paperwork up.  They had a copy of it, but the orientation was wrong and the signatures were cut off of the copy.  TIA.  That's a saying I have learned here.  It stands for "This Is Africa" and is routinely employed when things of this nature occur.  Fortunately, Amber helped to help me get new document signed and sent over in the middle of December.  Unfortunately, the entire Health Professions Council of South Africa went on Vacation December 15th.   They are just getting back into the office now (TIA).  I have been rounding in the hospital every morning, and have been scrubbing in on interesting cases, but do not have full privileges to operate on my own yet.  I should get my privileges sometime this week or next.  Please keep your fingers crossed for me.

Climbing up Table Mountain

It has been painful waiting, but I have been trying to make the best of it.  Since I have not been "on call" for the weekends, I have been traveling around South Africa every chance I get.  The "Danimal" came out to visit over New Years and we had a great time exploring together.  This picture on the right is when we climbed up Table Mountain (one of the new 7 natural wonders of the world FYI) via the India Venster Route.  It is known as being the most difficult way to ascend the mountain, and guides are routinely offered to help with the trail...  Guides? We didn't need no stinkin' guides!

From the top of Table Mountain

The view from the top was breathtaking.

Nature's Valley

We went to an incredible place on the scenic "Garden Route" called Nature's Valley.  The Garden Route is famous for its rich biodiversity, hosting some of the strangest, coolest plant life I have ever seen.  We did a 7 hour hike that included a 2km walk on the beach.  The Indian Ocean was a nice temperature and the swimming was epic.  This is a picture from the end of the hike looking down on the beach and valley that we traversed.

This is a waterfall we hiked to the next day in the backyard at the Wild Spirit Backpacker's lodge.  The people there were very cool and the atmosphere was amazing.  I played guitar all night by the bonfire and we made some good friends. 

Cape of Good Hope

We went to the end of the continent

Me, my kite and Table Mountain

In the days after I round, I have been learning how to kite surf.  It is an amazing sport.  I normally hate windy conditions, and Cape Town is one of the best spots in the world to kite surf because of the consistent wind.  You know the saying... "when life gives you lemons", so I have been fully embracing this new sport.  I met a really cool guy that owns one of the kite surfing shops locally.  If you haven't seen kite surfing recently, please check out this video of him. It's pretty short and will blow your mind:

http://www.youtube.com/watch?v=-TCedF9TCok

As you can see, I have been making the best of my "idle" time here in South Africa.  I am sure that my paperwork will be completed soon, and I will have a ton of interesting cases to share with you in the near future.  Thanks for checking in, more to follow.