Wednesday, June 06, 2007

Trauma call

Yesterday/this morning was my first call day--so much better than the other two days I've had. The student on call carries the consult pager which gets all consults from the floors and from the ED, as well as all the incoming traumas and his/her primary responsibility is going to see those patients rather than going into the OR or working in clinic. I saw a bunch of consults. One was a lady consulted to us by medicine who was discovered to have a hard lump in her abdomen--it ended up being mesh from a surgery 15 years ago, and now that she's lost weight it's palpable. There was a young man with a groin abscess in the ED whom we took to the OR for drainage (there was a lot of pus!). There was a lady with breast pain and drainage in the ED (6 months after having nipple ring removed)--she had a mass but not enough to be drained, so she'll get antibiotics for a week. Another was a lady with right lower quadrant pain x 1 day in the ED--CT scan couldn't rule out appendicitis, so she was posted for diagnostic laparoscopy. However, before we could take her to the OR we had a trauma come in. A youngish man had been waterskiing and somehow got his left arm caught in the tow rope handle, fell, and was dragged by the boat by his arm pit. He went to an outside hospital, then came to us three hours later. His arm was huge and tense, and we could not find any pulses by palpation or ultrasound. CT scan showed an open artery until about halfway down his upper arm, then it disappeared. We took him to the OR (the possible appendicitis lady wasn't critical)--it was probably the bloodiest (at least initially) operation I've yet seen. As soon as the resident made the incision about 1-2 quarts of blood streamed out covering his gown and the table in blood--the patient's arm looked like a deflating balloon. When they lengthened the incision we discovered that his biceps muscle had avulsed from it's point of insertion in the upper arm, had flipped down into his forearm, and was now hanging dead from his elbow. His main artery and vein were completely transected and he had a lot of nerves hanging around though his median nerve was intact. The vascular fellow and the resident harvested the patient's saphenous vein from his leg and grafted it between the two ends of the severed artery. They removed the biceps muscle and closed. The attending had me close the subcutaneous tissue of his leg which was very neat--the first time I've ever sutured more than skin. Plastic surgery will have to take the patient to the OR this week to see if anything can be done about his nerve damage. Unfortunately, the vascular surgery attending told me the patient even now has a 50% chance of losing his arm.

We were busy until about 0330, then I had to update the list. By the time I was done it was 0400, and since everyone else was coming in at 0530 there wasn't much point in going to bed. When everyone came in (there's something very cheerful about having the rest of the team come in after only having three people doing everything all night) we rounded on patients then went to Morbidity and Mortality (residents present cases in which something bad happened to a patient and attendings grill them mercilessly and yell at each other about what could have been done differently--though today was pretty tame, they must have been tired) and Grand Rounds. I then helped get all the morning labs, and at 1000 after working for 28.5 hours straight I went home and slept for 6 hours--it is odd how without using an alarm clock I always sleep for almost exactly 6 hours after being on call.


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