It’s the thing that feels like a wet noodle

I know I promised this story a long time ago and never got around to telling it. 

It was around 2am and a call came over telemetry that a young black male in his mid 20s was coming in with several stab wounds to his chest and unlike the young 15 year old in the other story he was already unstable: unconscious, extremely low blood pressure, bad heart rate. Everyone immediately got nervous and excited: there are very few indications to open up someone’s chest in the ER. One is penetrating chest wounds and hemodynamically unstable. But even then you don’t just go around cracking chests, it has to be within a certain amount of time and you have to have a reasonable chance at bringing them back. Most people go their entire residency and many their entire career without performing a thoracotomy or even seeing one performed. 

Everything happened fast. The trauma team swept down from their call rooms. The ER attending and senior resident mentioned to the trauma surgery attending that this seemed like a likely thoracotomy since he was initially stable when the paramedics arrived on scene and then started crashing en route. She wasn’t thrilled but said we could discuss it depending on how things progressed. We set up to run a full code. 

The patient comes in and everyone in the ER was there: two ER attendings, senior resident, the intern (me), trauma attending, the three trauma residents, 4 or 5 nurses, 5 techs, two pharmacologists, 2 radiology techs, 2 or 3 respiratory techs, the police, and the CFD paramedics. To say we had too many people would be an understatement, but everyone went to work. Thankfully the young man was already intubated when he arrived thanks to the great CFD paramedics. The techs got to work getting his clothes off, starting peripheral IVs, drawing blood, attaching heart monitors, performing chest compressions, etc. I tried to help them as best as I could. Since our work as ER physicians in traumas are mostly relegated to maintaining the airway and he was already intubated, my senior resident was helping the trauma surgeons explore the wounds. The trauma intern/junior went to work trying to establish a central line in the L thigh. 

The heart monitor showed minimal activity so they decided to open the chest and take a look at the heart and the aorta. The trauma senior and my senior poured a ton of iodine over the chest, gowned and gloved, opened a thoracotomy tray and made a giant incision along the top of the 4th rib. They opened it up stuck their hands in, grabbed a rib spreader and cranked it open. They exposed the heart and checked for any mechanical activity. Nothing. So they started internal cardiac massage. Essentially, you hold the heart in both hands and gently massage it to help it pump the blood. While one was doing that the other reached into the chest to see how the aorta was doing. “Feel for a long, big wet noodle. Normally it’d be thick but his heart isn’t beating properly so it’s not as full.” They found it and crossed-clamped it. 

In the mean time, the trauma intern was struggling with the central line in the thigh and couldn’t get it to thread. The whole process would be a waste if we didn’t have central access to the heart, so my two attendings took the drill and threaded two IV lines into the bilateral tibias (the bigger bone in the lower leg). Those are known as interosseous lines. You can pour just as much fluid into the bones as you can into the venous system and it goes to the heart pretty quickly. We started pouring in IV fluids and giving cardiac drugs. 

I went outside the trauma bay, back to the main ER to check on our other patients. There was one or two nurses out there; thankfully everything was ok. As I’m checking on some labs and xrays, a tech comes running out and says: they have a heart rate. I rush back in and sure enough the kid’s heart was beating again. My senior resident told me later that he was performing cardiac massage when the heart just started beating on it’s own. I can only imagine what that felt like. The trauma surgeons took him to the OR. 

I couldn’t believe it. It’s not often that we get someone back. Real life isn’t like House or ER where you do everything the right way and patient’s magically come back to life. Most of the time, when you get to that point, you’re already in big trouble. It’s very rare that you do a thoracotomy and get someone’s heart back. It seemed like a miracle. 

I found out a few hours later that he had lost his heart rhythm again just as they were about to begin surgery in the OR. He was shocked 7 or 8 times with the internal paddles and given several rounds of cardiac drugs but he had lost too much blood and there wasn’t anything more anyone could do. 

I always feel conflicted when I tell stories like this one. At the time it was both nerve racking and exciting to be in that room and watch people gently pull a heart from a chest and start massaging it. It was thrilling but it all seemed surreal for the patient. Almost like he wasn’t a real person we were working on, but another simulation. And then his heart started beating again and it all became real. I wasn’t involved when the surgeons spoke with the family. I can’t imagine how they felt when they were told that we momentarily had his heart beating again but that we ultimately weren’t able to save him. Were they angry that we put him through all that? Were they thankful that we did everything we could and had him back if only briefly? I don’t know, but I feel bad being as geeked and excited as I was. Maybe I’d feel better if the overall outcome was better. 

I don’t know.

Learning from your mistakes

Some days you walk in to the ER at 7am shift change and it’s an absolute mess. Usually this happens on Saturday mornings. People love to wil’ out on Friday nights. But when you walk in at 7am and the two senior resident’s who were supposed to leave at 5am are still there? That’s a bad sign. 

Everyone was crowded into one room with a 15 year old kid who was brought in by ambulance at about 3am. He was drunk and had gotten stomped out. I never found out where or why, but he was in pretty bad shape. He had been slowly decompensating over the last hour. He had 2 stab wounds to the back that were initially deemed to be superficial; they were explored and didn’t appear to be deep. But he was becoming more and more mentally altered. We attempted to have him transferred to a pediatric trauma center but they wouldn’t take him because he was drunk and “posed a danger to our other patients”. 

About 5 minutes after walking in he began talking incoherently and we decided to intubate him (stick a tube down his throat to help him breathe). Normally, 15 year olds are easy to intubate, but because he got stomped out, we had him in a neck collar and on a backboard. We couldn’t really manipulate his neck until we had insured he hadn’t injured his spinal column. Thankfully I wasn’t pegged to put the tube in. I was just asked to keep his head in alignment since we have to remove the neck collar to intubate. It went relatively well. 

The CT chest came back and showed bilateral hemopneumothoraces — in English that means that his lungs were collapsed from air and blood leaking into the space surrounding the lungs. He needed chest tubes on both sides of the chest to remove the blood and air and allow his lungs to re-expand. And needle decompression on both sides because some of the air was likely due to a traumatic lung injury. 

After that was taken care of, one of the senior residents signed out a few of his patients to me. They all needed follow up of various CTs — one was in a car accident and needed a spine CT to rule out injury, another was having severe abdominal pain and needed a CT to rule out appendicitis, and a third needed a chest CT to rule out blood clots in the lungs. I told him I’d follow up on everyone and disposition them appropriately. 

While everyone else was taking care of the 15 year old, I went to try and clean up the rest of the ER. I saw the 18 year old brother of the 15 year old (also drunk and post stomping out) who had his 3 front teeth knocked out. He was in a bit of pain and needed a head CT to insure there was no other injury. I also picked up a leg laceration in room 1 and a possible rectal bleed in another room. I went to see the guy with the leg lac first so the nurses and techs could get it cleaned up for me while I went to see the guy with rectal bleeding. It was a busy night like I said earlier, and he had been waiting for about 4 hours. Someone had wrapped his calf in gauze and as I unravelled it it was clear that except for the outer 2 or 3 wrappings it was soaked through with bright red blood. Now that’s not good. When I had unwrapped it fully the injury was still bleeding and rather steadily. It seemed like it was rhythmically gushing although it wasn’t spurting or pumping like most arterial bleeds do. 

I called a nurse and tech in and had them get together a compressive dressing while one of them put some serious pressure on the leg. I went to grab an available attending. One was helping a senior resident place the chest tubes in the 15 year old and the other was seeing other patients who had been waiting for 4 hours overnight. I went back to check on this guy with the likely arterial bleed. I had them remove the gauze. Luckily I have decent reflexes and was able to side step the spurt of arterial blood that flew across the room. I ran to grab the attending and had them move the patient to a different room. I checked his x-rays and he had two nice pieces of glass sitting somewhat deep in his leg. Apparently he had come home from the bars with his girlfriend and had slipped and fell onto a wine glass. The stem of the glass ended up stabbing him in the leg. Just unlucky as hell. 

We ordered a CT angiogram of the leg which allows us to look at the vasculature and see which artery is injured and how badly. While all this was going on the CT scan of the spine for the patient who was in an MVC came back and was read as having no fractures, dislocations or other abnormalities by the radiologist. I put a note on the board saying “CT negative, home soon???” to remind myself to discuss it with the attending covering the case, who was currently still helping to put the chest tubes and decompress the 15 year old. 

The CT angiogram came back and showed that the artery was injured but not completed severed and there was still blood flow in the lower leg which is excellent considering the nature of the injury. I called the vascular surgeon on call, explained the situation and asked him to come in. I made a follow up call to the dentist on call to have them come and check my 18 year old with the knocked out teeth. His CT head was normal and I just needed a dentist to determine what else we needed to do with the teeth. 

As I was making these calls, the attending taking care of the 15 year old came out and asked what had happened to the guy in the car accident. I said that the CT was negative but I hadn’t had a chance to check on him. He said “Well he’s off the board… where did he go??” The nurse then popped up and said “The note in the computer said CT negative, home soon?, so I checked on him. He had discharge paperwork and scripts in his chart so I checked him out, he had no pain, so I sent him home.” I explained that the senior resident who signed out to me had done the paperwork before he left but that the patient shouldn’t have been discharged until being seen by the attending. The nurse maintained everything was fine, but the attending was about to have a break down and kill someone. Apparently the last time he saw the patient, he had still been complaining of neck pain and tenderness, which even with a normal CT spine can be indicative of an occult fracture. I apologized profusely and offered to pull the chart so I could call the patient at home and have him come back to the ER for a re-eval. The attending said he’d think about it. 

After all of this went down, I went to check on the patient with the arterial leg bleed. His pain was well controlled and he was feeling better. He needed to use the bathroom so I told him to walk slowly and carefully. Not 2 minutes later I hear a yell. As he turned the corner he began re-bleeding in his leg. Blood was pouring down his leg now as he hobbled back from the bathroom. We got him back on the bed, flipped him upside down and started pouring IV fluids into him. We were still waiting on blood from the blood bank. The trauma surgeon showed up and asked what the hell happened. I said “He needed to use the bathroom and I told him it was ok to walk. It was my mistake, it didn’t occur to me at the time that he shouldn’t walk.” She looked at me, looked at my attending and said “Well at least he’s smart enough to know he screwed up.” I spent the next 20 minutes applying pressure and trying to get a compressive dressing to stop the bleeding. Just as we had that accomplished, the OR called down for him to go up. I apologized for letting him use the bathroom and he said “Apologize for what? I sat in the waiting room for 4 hours before anyone saw me. You were the first person to see me and figured out what was going on. You made a small mistake, no one died. We live and learn, right? ”

The attending for the MVC found me the next day and apologized for flipping out on me. He said that the guy would have likely gone home anyway and after talking to the nurse some more it seemed like the patient really wasn’t in pain any longer. I apologized again and said that in the future I’d make sure to better communicate our plan with the nurses, especially with a patient who was signed out and already had discharge paper work in his chart. As for the guy with the leg bleed, they repaired the artery but he needs another operation in a month for some further repair. 

As far as mistakes go, these weren’t the worst, but that doesn’t really matter to me. A mistake is a mistake. To me both cases illustrated the need to run things by my attendings. I felt like I was handling everything pretty well that day and it just never occurred to me that I shouldn’t let an arterial injury walk to the bathroom. Thinking about it now, it seems obvious. At the time though, his pain was well controlled and he wasn’t bleeding. He was in good spirits and just wanted to take a piss. What could be the harm in that? Apparently much more than I had imagined. Which is why residency is here and why we have attendings backing us up. 

And not that I ever entertained the idea that I was perfect, but that day really helped to emphasize how easy it is to make mistakes in this job. Most mistakes don’t jeopardize lives, but they can add uneccessary pain and suffering. Thankfully my patient was understanding about the entire situation, but it doesn’t make it any easier when you go back over it in your mind.