12.30.2006

Intro

I guess I probably fell in love with the trauma bay when I had my hands in a man's chest, his heart in my hands, squeezing blood through him.

Before he showed up, the trauma attending gave us an into...listen up, this man's coming in with a penetrating trauma to his chest, we're going to do what we can to establish an airway but we need to be ready to open his chest here in the ED...and so on. The worry was tamponade, a stab wound that involved the pericardium, or the sac around the heart; if it fills with fluid, the heart can't beat and the patient dies.

The gurney came in and, since I haven't been in that many traumas, I saw chaos ensue. Four nurses and doctors around the head, two more on the left side of his chest, two on either side of his groin, one at his feet, with nurses and radiology techs in the room as well as paramedics at the door of the bay, yelling what they found at the scene. In a less serious trauma, the medical student (me) has the job of recording the physical exam, which is set in a trauma. In this case, we never got past attempts to revive him.

An ED thoracotomy is performed by incising along the fourth intercostal space, creating an incision along the patient's side about at the nipple line. The ribs spread enough to fit your hands into the chest. The trauma attending and the trauma chief, a fourth-year resident, did this; I saw the initial bloom of sub-Q fat with the incision, but to this day it stands visually how little bleeding there was. The chest was opened, tongues of lung pressed back, and the pericardium, pearlescent, was seen. The chief made an incision, still with little to no bleeding, in the sac, and the attending, urgently voicing instructions all the time, had his hands around the heart.

At the same time, the two docs at the groin and a nurse at either arm were trying desperately to find a line. Finally, a flight nurse at the head, whose job was not finding an IV line, said he was trying at the EJ (the external jugular), and within less than a minute he had an IV line and two large heaters holding blood and fluid were opened to try and give volume back to the patient. With volume, the attending and the chief could start direct cardiac massage, squeezing the heart to distribute the blood; the hope was that the residual electrical activity the heart had, called PEA, or pulseless electical activity, could be shocked into a rhythm. They pulled out internal paddles, like the defibrillators used on TV but designed differently, silver disks that fitted around the heart.

The pace was fantastically fast to my eyes, but the attending probably knew how futile it was from the start. He had the presence of mind to ask where I was, and I had fortunately had the presence of mind to put on a pair of sterile gloves and step towards the center. He pulled me up and showed me where to put my hands, inside the pericardium which was amazingly stiff and resistant to stretch, and around the heart which felt like a tensed muscle but was squeezable, and with flat hands on either side, I squeezed blood out of the heart, trying to stay at the 100 beats a minute set by CPR training.

He died. He was likely dead on arrival, in retrospect. I looked for the article in the newspaper the next day, and he had been stabbed almost 15 minutes before he arrived. More telling, he had a stab wound in his leg which squirted blood after the tourniquet was removed, probably from blood given during the resuscitation attempt. Although he came billed as a stab wound to the chest, the one in his thigh may well have been the one that troubled him more.

So that's why I'm an M3 in Madison considering EM as a career. More to come.

3 comments:

Erica said...

Amazing.... I wish I could have seen it.

aaron said...

Ahhh, you'll see your share. Not to worry.

Matiram said...

Yeh,
This is really driving case you were with aaron. I'm really impressed with the case and enough to inspire you in emergency medicine.
Hope to read more from you.

Best wishes,
mati