Monday, October 20, 2008
Long 4 Nights

It is near the end of my fourth night at work and it has been a busy weekend. Thursday night I spent most of the night in a case involving a 4 year old boy with an abcess in his neck. The cause of the abcess was uncleaar but it was very deep in his neck under his jawline. Because there are many nerves, arteries and veins in the area where they were working it took the surgeons 5 hours to work their way down to where the abcess was. Fortunately the little boy woke up just fine and should make a complete recovery.

Friday night we took out the appendix of a 13 year old boy and performed a D&C on a 22 year old woman who had unfortunately had a miscarraige. Both cases were pretty routine and went well.

Saturday night started out very quietly and stayed quiet until about 1 in the morning when a 61 year old man was brought to our hospital by helicopter from a small rural hospital. He had been in an auto accident and had severe injuries. He already had a breathing tube in place and had recieved 8 units of blood on the helicopter but he was still bleeding internally. The surgeons removed his spleen as well as a large section of intestine. His liver also had a large bleeding laceration that they worked on. I gave him 10 more units of blood products. I left the breaqthing tube in and took him to the intensive care unit. I checked in on him tonight and he remains in critical condition and will require further surgery in the next day or two.

Tonight I did two cases. The first involved a 61 year old man who was getting a kidney transplant. He had a liver transplant 16 years ago and had been doing well until his kidneys failed about a year ago. he had been going to dialysis three times a week since then. They surgery took about 4 hours but it went well. The kidney was producing urine already even before we got him to the recovery room.

My last case of the night was on a 41 year old woman who is a heroin user. She had a large, painful abcess on her left hip caused by injecting with a dirty needle. It was a short 30 minute case.

It is now 5:30 in the morning and the day shift will relieve me soon.

Comment (1) | Trackback posted by Mike at 10/20/2008 05:13:00 AM

Sunday, October 12, 2008
16

It is near the end of my second of three nights at work. Tonight has been mostly quiet. I finished the case of a 20 something year old prisoner with a fractured jaw. I was told that he had been weightlifting and lost control of the bar and it had fallen on his face. I don't know if that was true or not but his jaw was broken in several places.

Friday night was busier. Most of the time we have some notice that a trauma is coming up from the ER. A beeper goes off and the message is something like 991-10. This means an emergency case is 10 minutes from the hospital coming in by ambulance or helicopter. We then call the ER for details and if they say it is potentially a surgical case then we gear up and get ready. Occasionally the phone will ring to tell us some emergency case is on the way and we may only have a minute or to to be ready before the patient arrives. We keep two operating rooms ready for trauma at all times with all the equipment and drugs ready to go for just these kinds of times.

On Friday I was actually interviewing a patient who was about to go to the operating room and have her gall bladder removed. The phone rang and the clerk call out "open chest case they are coming up now!" The lady needing her gall bladder removed was put in the recovery room to wait and about 2 minutes later the elevator opened. The patient was a young woman. She already had a breathing tube in place. Her left chest was already opened and one of the surgeons had his hand on her heart doing CPR by directly squeezing her heart. As we rushed her into the operating room we were told her car had been hit by a semi truck. Her heart rate was about 80 and she had almost no blood pressure. This was not normal. With such a low blood pressure her heart should have been beating rapidly to try and raise the pressure. Generally only a couple of things will cause the heart to beat that slow under those conditions and they are all bad. She could have a spinal cord injury where the heart doesn't get signals from the rest of the body and does not get the message to speed up or it could be a sign of severe brain injury. The quickest way to check for brain injury is to look at the patients eyes. If one pupil is significantly bigger than the other it can be a sign of a stroke or bleeding in the brain. When I looked at my patient's eyes I saw the worst possible thing. Both of her pupils were huge with almost no iris showing. They did not shrink when a bright light was shined in them as they normally would. The medical term for this is that her pupils were "fixed and dilated" which almost always signifies severe brain damage or brain death.

The surgeons quickly opened her abdomen to be sure her low blood pressure was not being caused by internal bleeding. There was not any bleeding.

From the operating room the patient was taken for a CAT scan of her head to confirm the brain damage. We heard later that she was officially declared brain dead a couple hours later. That is when we found out she was only 16 years old.

I went on that night to do the case of the women getting her gallbladder removed as well as another minor case.

Comments (10) | Trackback posted by Mike at 10/12/2008 05:50:00 AM

Monday, October 06, 2008
My weekend at Work

Last night was my fourth night in a row at work. Thursday and Friday nights I had a student with me. We did several cases Including a 40 year old woman with damage to her right eye. Saturday night was quiet with no cases at all.

Last night I was very busy. My first case involved a 16 year old boy who was involved in a hunting accident. He had been accidently shot in the hip by his father. It was a .30-06 bullet which is a large caliber round. The bullet had hit the head of his femur (the large "thigh" bone of the upper leg). The femur head was essentially destroyed and there was the possibility that bullet and bone fragments had traveled into his abdomen. After I put the boy to sleep the surgeons looked into his abdomen with a laprascope. They found no internal damage. The orthopedic surgeons then took over the case. The drove a pin through his femur just above his knee. It will be used to place his leg in traction until they can do further surgery. The surgeons will probably have to do a hip replacement on the boy in several days once the swelling has gone down.

The second case of the night involved a 40 year old man who had been drinking and put his arm through a plate glass window. He had a very large laceration on his forearm that was bleeding profusely. The surgeons found that the radial artery had been cut. They were able to repair the artery and restore circulation to his hand. Unfortunately the radial nerve was also cut and they were not able to repair it. The patient will not be able to move the thumb and first finger on that hand.

I finished the night taking out the appendix on a otherwise healthy 42 year old women.

Comments (2) | Trackback posted by Mike at 10/06/2008 05:21:00 PM

Sunday, September 28, 2008
Shotguns and Drunk Drivers

This is the last weekend my current student will spend working with me. It has been a good rotation for him with a number of trauma cases. This weekend so far he has seen the extremes of the night shift. Friday night was quiet. We did not do a single case. I spent the night watching DVD's and he spent it studying for the certification exam he will be taking for graduation in November. Last night was different. It started quiet but from about midnight on we got extremely busy. Our first case was on a 36 year old man who is severely mentally challenged. Mentally he is the equivalent to about a 1 year old child. He had a history of seizures. He had a shunt that had been placed in the past that drained excess fluid in his brain into his abdomen. Unfortunately the shunt was badly infected and needed to be removed. The patient was septic with a low blood pressure and a temperature of 104 degrees. His case went smoothly and with antibiotics his infection should be eliminated.

The second case of the night involved a 19 year old man who had been shot in the abdomen at close rang with a shotgun. He had almost no blood pressure on arrival to the operating room. We started giving him blood products as fast as we could and the surgeons went to work. His spleen was quickly removed as well as his left kidney which was shredded. He had multiple holes in both his small and large intestine as well as holes in his abdominal aorta. We gave over 16 units of blood products very quickly and the surgeons worked as fast as they could but unfortunately we were not able to save this young man. The damage done by the shotgun blast was just too severe.

Our next case involved a 19 year old girl who was involved in a multiple car accident. We heard that the car she was in was hit head on by a drunk driver going the wrong way on the freeway. Even though she had her seat belt on she still had significant injuries. The surgeons removed her spleen as well as several damaged segments of small intestine. We gave her 6 units of blood and left the breathing tube in at the end of the case. She will probably require at least one more surgery in the next day or two.

While my student and I were doing that case the drunk driver was being worked on in another room. His injuries were very bad including damage to his liver, spleen, intestines and spinal cord. He did not survive.

Hopefully tonight will be less busy.

Comments (3) | Trackback posted by Mike at 9/28/2008 06:43:00 PM

Monday, September 22, 2008
I Wish a Student Had Been There.

Saturday night at work turned out to be very eventful. It would have been a great night to have had a student working with me. About midnight we got word of an 18 year old with multiple stab wounds that was being brought to the operating room. The surgeons planned to place chest tubes on both sides and then to look inside his abdomen using a laprascope. They do this to see if there is any internal damage. It is easier on the patient to recover from several small scope holes. If they see damage with the scope they can then do the big incision down the front of the abdomen and repair the damage. The patient was awake when he arrived but he was obviously intoxicated and semi incoherent. I put the patient to sleep and the surgeons started to work. Initially they saw no evidence of internal damage to the stomach and intestines. Within a short time I started seeing irregularities in the patient's heart rhythm. He started having premature atrial contractions (PAC's). This irregularity is not uncommon and by itself is not life threatening. To see it in an 18 year old boy however is uncommon. It could mean that the boy had a congenital heart problem or that his heart had been injured when he was stabbed. Another likely cause in this situation is that the boy had been taking drugs. There are a number of illegal drugs that can cause irregular heart beats. Cocaine and methamphetamine are especially known for cardiac affects.

I told the surgeons about the irregular heart beats and they decided to do a pericardial window. This is where they make a small hole in the pericardiam which is the sack of tissue surrounding the heart. This would allow them to see if the heart had been injured and was bleeding. Using the scope they looked at the pericardiam and started to make a small incision. As soon as they started the patient's heart rhythm changed to one called ventricular fibrillation. This is a deadly rhythm where instead of beating in a coordinated way the heart just quivers and shakes like a bowl of jello. This is the situation you see on TV where the doctors use the paddles to shock the victim to restore a proper heart beat. The patient's heart was not pumping any blood and he would die unless we could restore a normal heart beat. The surgeons took a scalpel and quickly opened the boys chest. One of them started squeezing his heart with his hands to make it pump blood while at the same time the internal paddles were opened and prepared. With the internal paddles we were able to directly shock the heart. With just one shock his heart beat returned to normal. I gave the patient medications to help the heart beat stay normal. The surgeons were able to then finish the case. I left the breathing tube in at the end of the case and we took him to the ICU.

Tonight I went over to see how he was doing. He still has the breathing tube in but he has been awake and following commands so hopefully there was no brain damage. His heart beat has stayed normal and it looks like he will recover. I talked to the nurse taking care of him and she informed me that he had tested positive for methamphetamine.

My second case of the night was also challenging. The patient was a 45 year old man with a strangulated hernia. This is where a loop of intestine gets twisted in a hernia. If it is not treated quickly the piece of intestine can die and will then have to be removed. This case was complicated by the fact that the patient was 5 foot 9 inches tall and weighed 300 pounds. He informed us that when he had his gall bladder removed 8 years ago he was told "they had a hard time putting the breathing tube in for my surgery." He had no further information and we did not have any records from the previous surgery to see what had been done then. Normally when I do a general anesthetic on a person I give them medicine in their IV that makes them completely unconscious then I place the breathing tube in their throat. In this case I could not be sure that the breathing tube could be placed in the normal way. If I put the patient to sleep and could not get the tube in it is possible that he would not be able to breath and would then die. It was decided that we would do an Awake fiberoptic intubation. This means the patient would be sedated but semi awake as we placed the breathing tube in place. Several injections to his throat and medicine sprayed into his mouth numbs his throat eliminating the gag reflex. The beauty of this technique is that the patient continues to breath on their own for the whole procedure. It took several minutes but I was able to place the breathing tube through his nose into his lungs. I was relieved by the day shift before the case was completed.

It really is a shame that I did not have a student with me

Comments (3) | Trackback posted by Mike at 9/22/2008 03:19:00 AM

Saturday, September 20, 2008
As Promised

I promised mom in my last post that I would write about any interesting cases that I do this weekend. Thursday night turned out to be a very busy night.

First a little background information. Last Sunday (13 Sep) My student and I did a case involving a 45 year old woman who was kayaking on a river after dark. She and her kayak were struck by a fast moving motorboat and she was severely injured. Her spleen was ruptured, her liver had several large heavily bleeding lacerations, she had multiple broken ribs with a collapsed lung and other injuries. She had been in cold water and her body temperature was only about 89 degrees at the start of the case. This made things much more difficult because the low temperature interferes with proper blood clotting and can cause her heart to beat irregularly. We raised the room temperature to 90 degrees and used fluid warmers to try and raise her temperature.

The surgeons removed her spleen, placed chest tubes to re expand her lung and attempted to stop the bleeding in her liver. After several hours of work her body temperature was up to about 95. She had received over 70 units of various blood products but was still bleeding. The surgeons ended up packing sponges around her liver and temporarily closing her abdomen. we took her to the ICU where she would receive more blood products in hopes that her blood would start clotting normally again.

Having seen other cases like this one in the past I told my student that I thought she had only a very small chance of surviving the next 24 hours but since it was our last night on duty we might not ever know how she did.

It turns out she survived for 5 days. She had several other surgeries including brain surgery for bleeding in her brain. Late Thursday night she was rushed to the operating room again. Her right lung, the one that had been damaged by broken ribs, had suddenly started to bleed again very badly. The surgeons did everything they could and I gave her more blood products but this time we were unable to save her. I think that the severity of her initial wounds compounded by the complications caused by the low body temperature were simply to much for her body to overcome. Honestly I was truly surprised that she had survived more than 24 hours.

Comments | Trackback posted by Mike at 9/20/2008 05:16:00 AM

Thursday, September 18, 2008
Because Mom Told Me To.

Yesterday Thumper and I went up for a visit with my mom. We had a great lunch at Olive Garden and then spent some time at her house. She was having a small problem with her computer that Thumper was able to help her with. Then she asked me why I had not updated my blog in about 3 weeks. I had no excuse other than blog laziness. Their have actually been a few good cases that I and my current student have done the last 2 weekends I just never got around to actually writing them down in the blog.

So Mom, this blog entry is for you and I promise that if I do any interesting cases during the next 4 nights I will write about them too.

Please don't send me to bed without supper!