Medicine From The Trenches

Experiences from medical school, residency and beyond.

We have a mess here…

I settled into an evening of reviewing my lecture for the next day. It is a lecture on the early recognition of the signs of shock, a topic that is “near” and “dear” to most surgeons. This lecture is one of my favorite topics because I deliver this information in a “user-friendly” manner that I wish I had received in medical school. It took years of training in graduate school, medical school and residency/fellowship for me to “make peace”, read comfortable, with early recognition of signs and treatment of shock. Once the peace had been exchanged, I worked out what experience has taught me and my colleagues and pass that on to my students.

As I tweaked a slide here and there, the emergency tone on my phone sounded. Odd, I thought, for me to get this call on this day because I was not even on back-up duty. I called the number and heard the voice of one of my colleagues who is a trauma surgeon. “I have a young woman; shot multiple times in the upper torso and neck”. “Can you come in because we have a mess here and I need another pair of hands?” Of course, I would come in if called, without hesitation as one of the sheer joys of what I do is the old surgical mantra “A chance to cut is a chance to cure”. Besides, if I had made the same call to any of my colleagues, they would be at my side as soon as they could.

I drove my 1997 rusty gold Toyota Corolla through the sheets of rain that were falling as I made the 20-mile trip to the hospital. If I had been on call, I would have stayed at the hospital but since I wasn’t, I had to drive in. The rain pounded my wind screen in the early evening darkness. Why do these  types of situations happen on cold, rainy and foggy nights? Even my chihuahua would not venture out on a night like this. (I left my heated throw on low for her to snuggle into as I left my townhouse). ” A night that is not fit for man nor beast.”

I arrived at the hospital, parked the car and headed in through the emergency department. This was the quickest way to get to the operating room and would allow me to check out the radiographic studies before I headed upstairs. I scanned all of her films with the radiologist on duty and headed up the four floors to the main operating room. “They are in Room 6”, the desk clerk said as I removed my wet coat and entered the women’s locker room.

I changed into scrubs and grabbed my headlamp from the top shelf of my locker. I piled my wet hair on top of my head, pulled on a scrub cap, shoe covers and then placed my headlamp; tucking the cord into my back pocket. I peeked into the room where my partner,covered with blood, winked at me as a sign of relief. I  grabbed my surgical loupes from their wooden box, already placed on the circulator’s table, and said I would be right in as soon as I finished scrubbing.

The surgical scrub is where I take the time to center myself and get into the ritual, the mood of beginning a case. I always say a prayer for God to guide my brain and hands and to guide the hands of those who will operate with me. This has been my brief meditation as I scrub since medical school. I take the time to relax my arms, shoulders and breathe slowly, deliberately before I move into the operating room. With all of the tension of the drive, the rain and the run up four floors gone; I am ready to get to work.

I never want any surgical case to be mindless. I want to be mindful of every step and every event that will unfold. For the patient on the operating table, nothing about what I do is ever routine and will in all likelihood, be a sentinel event in their lives. Once something is cut, it’s never the same as before the cut. No, there is no mindless routine for me or for the patient but for me, there is a sense of compulsive perfection to get it right and to get it done.

The patient had been shot multiple times with wounds in the neck, upper torso, abdomen and shoulder. She had been standing outside her house with a group of friends when a car pulled up and multiple shots were fired. A policeman, was present in the operating room to take all bullet fragments that we would remove. As I donned my surgical gown and gloves, my partner motioned for me to take over the shoulder vascular repairs that he had been working on so that he could move to the abdomen. From training and experience, get control and make the necessary repairs and move onto the next task.

My partner had completed only a tiny portion of what needed to be completed in this complex wound. The bullet had shattered two bones in its trajectory but the vascular damage was immense. I completed a couple of repairs to larger vessels and proceeded to take care of some of the smaller vessels. It was going well and she would have a good blood supply around this mobile joint.

I moved to the upper arm as my orthopedic surgery colleague moved in to do his part with this case. The bone repairs needed plates and screws. Not great to put hardware into places where filthy bullets had been but there are techniques to avoid infection. Most of the tissue that had been in direct contact with the projectile had been removed because it was not salvageable.

The upper arm wound was a clean pass-through which I explored and closed. This would need broad spectrum antibiotics but not a major vascular repair. My trauma surgery colleague had started to explore the abdominal wounds assisted by a resident as I completed the upper arm repairs. The anesthesiologist said that she was holding well and wouldn’t need any further transfusions. We were getting ahead of the damage one “mess” at a time.

“I am going to run the bowel and get out of here”, my trauma surgeon colleague said. “How’s things going up there?” , he asked. “We are almost done,” my orthopedic surgery colleague said. I looked at the neck wound which had amounted to a superficial graze with no penetration of the platysma, a sign the residents had not missed on their initial exploration in the emergency department. The torso wounds had been superficial largely, because of the angle she stood from the shooters.

I helped the orthopedic surgeon close above his work and then turned my attention to helping my colleague close the abdomen. In all, there were seven people around this patient, a diminutive young woman of 19 years. She would not remember those of us who worked on her that night in that operating room but she would bear the scars of being in the wrong place at the wrong time. She would live with some loss of range of motion in her left shoulder but she would be able to live a relatively normal life.

What would she change about her life after this event? Even more important, who is she and why was she in front of 8 bullets on a cold, rainy and foggy night?  Who was so cruel that they inflicted this on this woman who was approximately 25 feet from the car when she was shot? This woman is 19-years-old and just starting adulthood but could have been dead from this event. I would receive answers to some of these questions in the coming week after this case but some of the answers will never be known.

There is no “ego” to making these repairs and doing this work. There is a compulsion, on my part, to try to get the best outcome possible for every patient. I see damaged vessels and try to affect the best repair possible for restoration of their function. The wounds have to be explored, evaluated and repaired. There is no value judgment on these types of wounds; only repairs and restoration of blood flow. Get control and get the repair done as safely and as completely as possible.

This young woman is an honor student today with a passion for the study of literature. She has almost completed her undergraduate degree and is poised to enter graduate school. She is mindful, contemplative and readily shares her story with those who have a life of violence either by choice or not. She was visiting her grandmother the evening of the shooting and had just arrived in our city. She didn’t know any of the young people in the car, that shot her.

 

 

 

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27 December, 2015 - Posted by | medical school, on-call, practice of medicine, surgery, trauma, vascular surgery |

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