See? P.R!

If you watch medical shows on TV -- and who doesn't? -- you can be excused if you think CPR regularly raises people from the dead. What could be more dramatic? All those close-ups of concerned (and uniformly handsome/beautiful) doctors, nurses, medics, heroically pounding on chests, turning to look at a monitor as it suddenly changes from flat-line to perfect wave-forms. Like nothing had happened. Sadly, it doesn't work that way very often. On the other hand, surgeons have a better crack at it than most, literally.

I've written before, so I won't again now, about the drama of cracking a chest in the ER, clamping the aorta or putting a finger in a hole in the heart. Take a young person with cardiopulmonary collapse from a non cardiopulmonary cause (like exsanguination from an injury), or from just the right cardiac injury, and make the circumstances perfect -- like arrival quickly at a well-run and properly equipped ER -- and you can be part of something memorable. A person in profound shock from sepsis: with the help of many people -- intensivists, nephrologists, ICU nurses -- a well-timed operation can be a part of a heroic rescue of a life that was nearly lost. These things are a part of surgery, and can be exhilarating in the looking back. In my case, it's hardly a high-five'n sort of thing. It's about being in the right place at the right time to be involved under the right set of circumstances in doing the right thing. As opposed to how it usually goes. Which is why "heroic" really means "lucky." A reader asked about what it's like to resuscitate someone. I hope she won't be disappointed.

"Code Blue, room 326; Code Blue room 326; Code Blue room 326...." My first response is to run the room number through my mind to figure if it could be my patient. And whether it could be, or clearly isn't, it's always a sense of dread and doom at what I'll find. Being painfully honest here, I'll also admit that if it's a medical floor my response is slower: I figure there'll be plenty of people more capable than I at running the show, and I may sidle up slowly to see if they need something mindless like inserting some sort of tube or access line... "Oh boy!!" is the last thing I -- or anyone but maybe a student -- think when I hear the call. Odds are, it's not going to end well. In fact, various particulars aside, one can get pretty good mental image of what will be found, based on many repetitions of the same thing.

Chaotic and crowded, the room will be full of people and machinery; a "crash cart" with drawers gaping open in disarray, popped vials strewn on top. A couple of nurses with clipboards, documenting. Possibly three or more docs, one at the head of the bed; likely having run up from the ER. Pharmacist, respiratory therapist. Students, maybe (in my situation, only nursing students). Thrilled; and horrified at being thrilled. Shocked, too; wondering if this is really what they'd had in mind. Disorganized from the broad view, there's usually in fact an overall calm in the principals, deriving in part from the fact that those responding most immediately have done it many times before; and maybe also from a realistic sense of the inevitable.

Remember this: people who arrest in the hospital must already be pretty damn sick. When they fail despite whatever it is that's being done for them, there's already been a stark selection.

Some things are nearly constant: protruding from under the patient is a polished board, maybe maple or oak. Cut-out handles visible at the edges; tubes, sheets, maybe bloodied, draped crazily. Someone kneels on the bed or leans over the edge (backs of knees aching within moments), hunching, with elbows locked, onto a bare chest (in the frail and old, the feel of ribs breaking, sternum cracking are among the more sickening sensations I've ever had). With each compression, the patient's arms flail a little, the belly shakes, the legs shudder. Looking at the feet, one sees ominous blue mottling, heading up the calves. The thighs are webbed with blue veins, as if spidery Death has been there, laying claim, marking territory. The more tubes already there, the worse the outcome. A bandage on the belly is like an address label to the morgue. The defibrillator is no Trekkian transporter. If it works, it bespeaks a particular set of circumstances. And you might be surprised to know this: the word "clear" is said, all right. But unlike those TV shows, it's not a shout. It's a question.

The call at three in the morning: "Dr Schwab, your patient Mr Jones is coding." "What, who, what's.... Nevermind, I'll be right there." I got into the habit of hanging next day's clothes on a hook, to save time rummaging, and to avoid turning on a light and waking my wife, because on a typical day, I left in the dark. It's useful for this situation, too. Holding the clothes in my hand, squirting a finger-tip of toothpaste and sticking it into my mouth, heading downstairs, dressing in the hall. Running possibilities over in my mind on the drive in. I always figured if flashed down by a cop I'd hang my stethoscope out the window and keep going; it never happened.

The feeling is horrible: it's a rarity, really, because most people do well. Or if they don't it's not unexpected. But on those awful occasions when there'd been no reason to expect it, it feels like you're driving with a boulder in your lap. When you get there -- from phone to floor it was give or take twenty minutes -- and enter the room a scene not unlike the above, eyes all turn your way. "What happened, how long has it been?" you say. "Anyone have any idea what's going on? Who's his nurse tonight?" She gives a review of the preceding events. A call like this, out of the blue, is extraordinary. If things had been changing, there'd have been contact; I'd likely have already come in. So this is a catastrophic event -- a stroke, a heart attack, a major blood clot in the lungs. You get a sense of the air in the room, the time. Feel the belly -- because that's what you do -- look at the pupils. Glazed and fogged, pupils black and wide as pools. Lips purple. Ears, too. Purple ears. "Anyone want to keep going? Any suggestions?.... OK then. Let's call it."

Sometimes it's not so bad: it's loss of blood pressure with a persisting heartbeat. A post-op bleed, some sort of infection. Then you can slam in a couple of extra lines, tilt the bed head down, squeeze bags of fluid or blood, watch parts pink up. See the eyes come open, feel feet get warm. Not to mention sense your own heart slow down, your armpits dry a little. It'll be OK. This time, it'll be OK.

Traumadramarama

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.