Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.
Wednesday, July 18, 2007
When there's as much shit flying from the fan as is compatible with known laws of motion, you slash open the chest, in the emergency room. There are reasons, and there are ways. For sheer speed, you cut between the ribs and then, at the end near the sternum, where cartilage takes the place of bone, you turn the knife northward and chunk through a few of those soft ends. It makes an ugly, L-shaped scar, but it's quick, and you can reach in as if through a trapdoor. It eliminates the need for finding, opening, inserting, and cranking a rib-spreader, breaking a couple of ribs in the process. Why do it? Well, for one thing, when someone is exsanguinating into his belly, a way to slow the flow is to clamp the aorta. Accessing it through the chest means staying out of the belly until you get to the OR; open such a belly in the ER, and the victim will bleed out in a heartbeat. A few heartbeats.
As a surgical trainee, cracking a chest in the ER is one of those things you look forward to with thrilled anticipation -- and before the first, with not inconsiderable uncertainty. (In private practice, valuing order and knowing you've been there and done that, generally you hope never to be in the situation where it's needed. Although the admiring murmurs it engenders never fail to stoke certain flames. "Wow" is an ego-pleaser, too, when heard after a successful rescue.) My first was for a stab wound to the heart; with the pericardium swollen and blackened by blood, I was momentarily disoriented and unsure of my landmarks. (In opening it, you want to avoid, among other things, cutting the phrenic nerve.) It's less messy when the purpose is to find and clamp that aorta, although it's a first surprise to recall how posterior it is.
Whatever the reason, once a chest is opened it's a thrustle (I like making new words. Thrash/hustle. Did you like "snork" in the previous post? I was thinking of snore/speak) to get the patient to the OR asap. If the aorta is clamped, you've effectively cut off blood flow to the entire belly and below: kidneys, liver, guts, feet. No time for doodling. You may or may not be squeezing the heart in your hand: external chest compressions have little effect when the heart is empty, so until those people I mentioned in the previous post -- working on several IVs and pumping the tank full again -- accomplish their goal, to get blood circulating you hold that heart and work it, even as it's still beating. And you can feel the engorgement, the ventricles filling more of your hand, the more powerful squirt in response to your grasp as the blood volume is restored. Carefully, with hope, you can begin to relax your grip, keeping your hand near, sensing the more effective beats; and finally, extract your hand from the chest, while realizing for the first time how awkwardly it's been bent, reaching in from the side of the patient, through a small, tight, and bony hole. As circulation returns to the patient (at least his upper body!), so it does to your hand.
It's not over. Even with the aorta clamped, opening the belly releases the bled blood, and it gushes out under pressure as the belly deflates. Backbleeding -- depending on the nature of the injury -- can still re-empty the heart; as can the simple act of releasing the compressive pressure of the belly wall. Clearing the field of blood as fast as possible, by bailing, mopping, suctioning, you aim to find the source of bleeding hemi-instantly, hopefully to get clamps on either side of the holes and releasing -- slowly -- the aortic clamp. Another opportunity for re-crashing blood pressure: while the clamp has been on, the distal blood vessels relax and dilate. Releasing blood into that now-larger vascular space invites a big drop. So you wait until the anesthesiologist indicates s/he's caught up and then some. With luck, you may already have been able to satisfy yourself it was safe to place a clamp below the arteries to the kidneys and remove the one in the chest.
First things first and second: a missile or sharp thing that got a vessel to bleed likely punctured some bowel as well. After gaining control of the bleeding, and before repairing it, it's time to have a look around for what else is wrong. If there are intestinal holes, they need pinching off in one way or another so they don't leak until you get back to them (Babcocks and Allis's work fine. Temporary whip-stitch for a bigger gash.) And there needs to be an even number of holes. If not, you've missed something! There are lots of opportunities and places in which you can do just that.
"Running the bowel" is the term for, in an orderly fashion, slipping the entire length of the intestine through your fingers, looking for trouble; flipping it over as you do it, so you see both sides. Trying not to let it slip out of your hands and lose your place. The colon, being either tethered to the periphery of the abdominal cavity, or draped in fat, or both, is harder to "run." You can't, really, so you need to look really carefully, and cut it loose to look behind if there's reason to worry. Likewise, the duodenum is fixed in place and held behind the transverse colon and into the retroperitoneum. Missed duodenal injury can be disastrous (they all can!); it's more likely in blunt trauma, wherein there's no knife or bullet hole to lead you in. You can read about my experience with that, in my book. (I -- and my patient -- lucked out.)
One of the cardinal rules of trauma surgery (particularly for penetrating injury) is, unless time prevents it, to get an image of the kidneys before you dig in; an image with dye that shows function -- not to mention confirmation that there are two of them. Among the apocryphal tales of trauma surgery is the story of removing a damaged kidney, to find out later that it was the only one, or the only working one. I assume it must have happened somewhere, some time. Happily, nowhere near me.
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the missing kidney scenario that they warn us about in academia...what follows is true. hijacker in our country takes on through the kidneys, thanks to a cop who couldn't get a head shot. he comes in and has an emergency nefrectomy (no imaging because he was exsanguinating and no time). only then was it discovered they had just removed his one and only kidney. i worked with this patient when he was waiting for a transplant, on dialysis obviously. he did stop his life of crime. it seems the dialysis interfered with his holding up and shooting innocent people.
so the lesson is the cop did prevent crime by shooting him in his only kidney. however it would have been cheaper to shoot him in the head.
From way back when I was on the transplant service, in the relatively early days of transplantation, I have a somewhat vague recollection of one of our patients having been injured or ill or something, such that he was taken to an ER, where a large mass was found in his right lower belly (iliac fossa -- where transplants are placed!). Can't recall the details or rationale, but a surgeon removed the mass/tumor, and was disappointed to see the man get worse...
ha ha ha. that's priceless.
while we are on anecdotal transplant stories, i once saw a guy also on the waiting list. he had an a-v fistel to allow easy access for dialysis. he went to a gp about some trivial problem. the gp found a large 'abses' on his forearm. he didn't notice it was pulsating. he did an i and d in his rooms....
amazingly enough he got to hospital before the bleeding stopped spontaneously (as it always will do)
Stop! Please! You guys are cracking me up here!
Reading this blog is better than watching ER. :-)
Damn good posts Dr Schwab. I love hearing about your experiences. It really makes me consider whether I should just say: "to hell with it" and go into surgery anyway. I get so rev'd up reading about stuff like this.
I'm a pathologist so I don't have trouble with exposure or bleeding. I found this post from Kevin M.D.'s blog and all I can say is, wow!! Glad you enjoy doing that kind of stuff; riveting reading.
All right, I have had enough. I am buying the book.
parameddan: spoken like the clear-headed person I'm sure you are...
"All right, I have had enough. I am buying the book."
You won't be disappointed.
Is it possible to be in awe of surgeons all over again...because I am. Wow!
Years ago there was an ED doc that would often comment that he had cracked a chest the night before down in the big city hospital he worked in. I'm guessing it must be a pretty common occurrence in a city ED.
Amazingly back then I hardly paid attention to what he said because the awesomeness of it all just didn't register with me back then. He was very interesting and funny but I just didn't appreciate the surgical stuff. My loss.
When you have a big hand - how the heck does it fit in and around all that stuff never mind hold and pump something? Just wondering.
Question: if rib spreaders aren't needed to access the thoracic cavity in an emergency, why are they included in the standard thoracotomy trays?
Or in other words, why doesn't everyone perform an ED thoracotomy the way you describe it?
Well, one reason might be cosmesis: the "trap door" method, while very quick, leaves a more unpleasant scar. Truth is, I guess I don't have a complete answer. To me, it's quicker and more direct, when the need is to get at the heart in a hell of a hurry (and if there's no hurry, you shouldn't be doing it in the ER).
On the other hand, I'm an old guy now; maybe it's like open chole. Thing of the past. Can't really say.
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