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.