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.