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.