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.