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.