Saturday, July 29, 2006

Memorable patients: part three

She was a Korean woman, spoke passable English. We always exchanged pleasantries, and she called me "doctor" when I picked up my laundry. This time she was notably quiet, distant. I didn't figure it out until I got home and hung up my jacket, on the inside of which I noticed she'd pinned an envelope. It contained a photo I'd taken months ago, left and forgotten in one of my pockets. What it showed was a nude female torso, sixteen stabwounds up and down the left side -- chest, breast, abdomen -- with the handle of a 12-inch butcher's knife buried to the hilt, protruding a couple of inches below her left breast. (Shakespeare said it so beautifully: "Over thy wounds now do I prophesy,--- Which, like dumb mouths, do ope their ruby lips..") Self-inflicted, after killing her care-giver.

The police had been called to a trailer park, where neighbors had heard screams. A schizophrenic woman in her twenties, living with a man in his forties who cared for her, had been off her meds lately. In a rage over who-knows-what, she'd first stabbed the man multiple times, then herself. He died. She didn't. She was mumbling but cooperative in the emergency room. Her vital signs were remarkably stable, despite the impressive amount of blood covering her; maybe it wasn't all hers. The knife handle rocked gently with her respirations, and noticeably twinked, ever so slightly, with her heartbeat. In the OR, we prepped her from chin to pubis, figuring we might be going in everywhere.

A cop accompanied us to the OR. Worried that I could cause a catastrophe if I did it blindly, I hadn't removed the knife: the cop needed to maintain "chain of custody." (Link added 12/09, after a reader question.) I opened her belly first: with stabwounds to the lower chest, the most likely place of injury is within the abdomen. Indeed, the knife had passed through the left lateral part of her stomach, and its sharp edge rested along the surface of the spleen, kissing it gently. Holding the spleen out of the way with my left hand, I withdrew the knife with my right, and handed it off to the cop, feeling pretty cool: surgeon, calmly and professionally cutting the lady open in front of the cop, handing him the weapon like I did it every day. He tagged it and bagged it, like he did it every day.

Thoroughly searching the abdominal cavity revealed no additional injuries, so I closed the two holes in the stomach (one thing about penetrating injuries: you need to find even numbers of holes in things: entrance wound + exit wound. And you "run" the entire bowel, meaning spooling it carefully between your fingers, flipping it over and back to look at all surfaces. Since intestine slithers freely, a stab in the upper abdomen can easily have injured bowel now lying in the pelvis). About the time I finished, the anesthesiologist started rooting around on the other side of the drapes, then hollered for help. The patient was crashing.

In the emergency room, I'd placed a chest tube on the left side, because the lady had caused herself a pneumothorax, so I knew at minimum she'd punctured a lung. Now I thought she might have nicked her heart as well, causing cardiac tamponade. With her blood pressure dropping rapidly to zero, there was no time for a tidy entry into her chest, so I did it down and dirty (for a nice description of this technique, see page 180 of my book).(And yes, I know it's shameless, but it's my blog...) Had it been tamponade, her pericardium would have been purple and swollen from underlying blood, but there was no such thing. Here's where my memory (several years ago) is cloudy: I can't remember if I actually saw the air bubbles in her coronary arteries, which would mean I probably opened the pericardium -- which I might not have, absent obvious tamponade -- or if I just presumed it as a process of elimination. Nevertheless, it's a thing that can happen when the lung has been cut, especially in the setting of positive-pressure ventilation, as happens during anesthesia. A cut lung allows potential entry of air into the pulmonary arterioles, which then returns to the left ventricle of the heart, from which it gets pumped out to the body. First point of departure from the aorta are the openings to the coronary arteries; an air bubble in them acts no differently from a blood clot, with the potential of causing a heart attack. Next points of departure lead right to the brain.

Following a protocol of which I was vaguely aware but had never used, I clamped the aorta downstream from the head vessels, had the anesthesiologist tilt the OR table as head-down as possible (routine for low blood pressure, but in this case also to keep any more bubbles from getting to her head), and asked him to give our patient drugs to raise her blood pressure as high as safely possible, and to run 100% oxygen (in addition to protecting ischemic tissues, it speeds up absorption of air). The idea of the high blood pressure is to force the bubbles through before doing permanent damage. Clamping the aorta that close to the heart raises blood pressure as well. It's potentially a dangerous combination of maneuvers, but as they say about desperate times...

At this point (if I hadn't already) I opened the pericardium, and sure enough, there were little bubbles in the coronary arteries.(See, I can't remember exactly when I saw the bubbles, but I clearly remember seeing them... This blog is gonna be an honest one, dammit.) As the pressure rose, I could actually see them moving along. And when her pressure began to get dangerously high, I incrementally released the aortic clamp, and amazingly enough, she was able to maintain her pressure, as she hadn't before. This, ladies and gentlemen, had been a very precarious situation, which turned out amazingly well. She woke up without obvious signs of brain injury, and her cardiogram returned pretty rapidly to normal. Sixteen stabwounds, seriously delivered; not a single after-effect. Dead caregiver.

Being young, and still occasionally allowing myself the misconception of surgeon as god, I figured that, having rummaged around quite considerably in her entrails and having held her heart in my hand, I of all people should be able to get through to this lady; certainly she'd express admiring gratitude. Well, of course, no. And not that it relates to the previous thought, but the psychiatrist I asked to see her -- it is my distinct recollection -- concluded she didn't need psychiatric hospitalization and could go straight to jail. Which she did, eventually, still mumbling. In retrospect, taking the picture served no useful purpose at all. I'd thought I might use it in some lecture or other, or a paper, and I'd taken it before all the excitement. But I never did. I kept taking my laundry to the Korean lady, and our conversations reverted to normal.


Anonymous said...

What a memorable situation!

Intelinurse said...

my standard reaction to your current "memorable patient" series has become, "wow"

how do surgeons, especially trauma surgeons, ever get used to a life of low-adrenaline after so many high-adrenaline situations, such as what you described?

Gregory House, PA-C said...

Okay after all these "memorable patient" posts I think I can safely remove surgery from my list of possible areas of interest. That stuff is just too nuts for me.

Anonymous said...

Dr. Scwab, I want to thank you for leaving a comment on my blog ... thus causing me to discover your own!

Excellent blog!

I've blogrolled you and added you to my Bloglines RSS.

Anonymous said...

!Didn't need psych hospitalization, especially when still mumbling?!?!

Ali said...

Ha, I had the exact opposite reaction to your post as Dr. Wannabe. These Memorable patient posts are awesome - educational as they are entertaining. :)

Kay Wotton said...

You have a geat gift for writing. I am still thinking about the Korean woman's reaction--and I like that.

Anonymous said...

Dear Sid,

I have been meaning to drop you a note for some while to compliment you on your book and how much I enjoyed reading it! I just had to contact Calvin to request your email so that I could contact you directly.

You have quite a talent, not to mention your memory! Who would have "thunk" to have logged so completely your life as it was being lived, especially with the hours you were keeping. I loved reading about your mentors, good and bad, your life with Judy and the rigors of your training. You gave me a glimpse into a time that I didn't share with Tom, as we didn't meet until his internship days in Fresno, CA. I am not a nurse, but a teacher, so have to some degree found the world of medicine fascinating and intriquing.

Tom has had too many other reading irons in the fire, but sends his best to you and Judy, as do I. Maybe some time along, we can stop en route to Seattle to say "hello". Be sure to keep us on your mailing list for your next book launch!

As ever

Brada Bailey

Anonymous said...

Interesting case. I was curious about the psych consult, as well. Perhaps the consultant felt that the patient could be treated in jail's facility. Clink, does that make sense? We often struggle with these questions in the ED... what can jail or prison handle and what can they not... especially wrt suicide precautions.

ClinkShrink said...

OK, I could have sworn I left a comment but it's gone now. Did I hit the edit instead of the publish button? This is certainly possible. Sadly, it was a brilliant (in my opinion of course) comment that's not easily recreated but I'll try.

The psychiatry consultant did the right thing. With potentially (actually, in this case proven) dangerous forensic patients you need to provide treatment in a secure environment. Only forensic hospitals are truly equipped to do that, and that kind of transfer could not be arranged within the time frame of a surgical admission.

Pretty much all jails have the ability to do suicide observation now. Larger jails have inpatient psychiatric infirmaries. Your patient most likely would need to transition through the correctional medical infirmary because of her post-op status.

The only thing that correctional facilities really can't do are emergency diagnostic procedures (eg. STAT labs, CT/MRI scans, urine tox screens, etc). That's the only reason I ever send a patient out to the ER for. I've sent a link to this post to another correctional blogger to see if he has any other additional insights.

Sadly, this case is not all that unusual in correctional work.

Sid Schwab said...

I really appreciate the fact that the clink shrinks have take the time to comment here. My mention of the psychiatrist in this case was sort of an aside. Naturally, I was more concerned with my part in the whole matter. Nevertheless, whereas I can't say for sure what sort of facilities were available in the prison, I think sending her there was not unreasonable. It's also true that at the time, psych resources in our community were at low ebb. I'm pretty sure the consulting person was not an MD. Nor do I have any followup to report after she left my care.

A!ice said...

Wait, I don't "get" it: why did the cop have to accompany you to the OR? Why did he have to see the knife being taken out???


Sid Schwab said...

Because of "chain of custody."

A!ice said...

Wow. I sure am glad that Wikipedia text also has built-in links, because I originally thought that "fungible goods" were ones which were prone to digestion by fungi. Oh boy!

Anonymous said...

I cannot believe the psychiatrist said she did not required hospitalization for mental illness! You should have had another psychiatrist do an assessment on your patient. You saved her life so that it would be ruined in jail or she would be put death, that is so ironic. But it sounds like police were like a dog with a bone.