Death's Door

Trauma surgery has rapidly become one of my favorite rotations. Despite the 14 hour days interspersed with 30 hour call days I find that I am not dying to leave by the end of the day like most rotations I've been on--I've even managed so far to successfully get out of bed at 4:30 (though historically I tend to get up progressively later as the month goes on, starting with getting to the hospital easily ten minutes early and ending with running into the workroom out of breath several minutes late). My most recent call day was Sunday/Monday and it was nuts from 7:00 AM until about 4:30 AM. The first consult I saw was in the ER, a man who had been on a riding lawn mower and made too sharp of a turn which caused the mower to rear up and flip over backwards--fortunately it did not land on him, but his thighs were covered with gasoline just before the mower burst into flames, which made him burst into flames. His inner thighs were totally burned and covered in huge yellow blisters. Fortunately for him the burns were mostly superficial, and we just dressed him with antibiotic cream, gave him fluids, then sent him home the next day with a healthy supply of narcotics. I wrote admitting orders for the first time, which ended up being quite a mess with things crossed out and sentences being continued several lines from where they started, but on the plus side my handwriting is actually legible which is more than can be said for a lot of doctors (but before anyone jumps on the doctor=bad handwriting bandwagon, a study was recently published which showed that doctors' handwriting is actually no worse than any other professions--the only group that had significantly worse than other professions' handwriting was male CEOs).

The next consult I saw was a man with a left buttock mass that had been growing for years--likely a hematoma as he has hemophilia. When I got the consult I was expecting a fair sized lump, but when I went up and saw him...wow. I have no idea how he functions at home. "Massive" was how it was described by the internist in the chart and I can't think of a word that better describes it (at least that one could write in a chart--"ginormous" might not be considered quite professional). I left before I heard the plan for him, but my guess would be that they'll recommend follow-up as an outpatient (he came into the hospital for other problems).

Around 10:00 pm we had a stab wound to the right flank come in. We took him to the OR for exploration, he was fine. As we were closing him, we got a call that a gun shot wound patient was coming in. The resident and I stayed to close while the attending went down to see the new patient. They rushed him into the OR, and as soon as our first patient was closed the resident left me to see him back to post-op and went in to the GSW case. I came in a few minutes later--they opened him up, and found a lot of blood in his abdomen. They searched around for a while (the patient was literally dying on the table at this point) and finally discovered that the bullet had shattered his left iliac vein--yet had somehow missed the artery that overlies it. At this point there were four doctors surrounding him, so I couldn't see everything clearly, but it was the most intense operation I've seen yet--I wasn't very optimistic as to his survival. Amazingly (and providentially) they were able to repair the vein and I went and saw him this morning. His only complaint was that he was a little sore.

The highlight of today (though very tragic) was an 18 year old with a self-inflicted gunshot wound to the head. In the ER they stabilized him with IV fluids and intubated him, then we rushed him to the CT scanner, then rushed him to the ICU. His pressures were practically nothing, and his pulse was very high indicating hypovolemic shock secondary to bleeding out through his head; several attempts were made to place IVs, and finally they just put a central line in. This unfortunately is one of the cases where despite hours of working on him, most likely it was all in vain--he had brain tissue coming out of the bullet holes which is not a good prognostic indicator.