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.
Hospital Stories: My Intern Year... and Hopefully Beyond 