Chief resident calls (part one)

It began like any other Sunday on call. Rounds with my team, breakfast, and then table rounds with our attending and the other two teams before walk rounds. I was blessed to have the dream team on call with me, reliable, dependable people who took pride in their work and worked hard. As a chief resident it made my life so much easier because I knew shit would be taken care of. Our hospital on Sundays had bare hallways, things always seemed to move at a slower pace. Options in the cafeteria were limited so we often ordered Chinese food or on this particular day our attending ordered pizza for us. For the most part it was a quiet day, a few straight forward nonoperative consults in the ED and traumas which consisted of elderly patients on anticoagulation falling and sustaining minor injuries.

traumaIt was close to midnight and I had just settled into my call room when the operator announced overhead, “attention please, attention please, trauma team bravo to the emergency room, trauma team bravo to the emergency room.” I dropped my book as though it was on fire and ran down the stairs to the first floor and cut through the outside to get to the ED. It was a hot and muggy summer day but I loved the feel of being outside even if it was for a few seconds. We had three levels of  trauma activations. Alpha was the highest level which the anesthesiologist had to come to the trauma bay and the OR had to get a room ready immediately, for things like penetrating trauma. Bravo was serious but not immediate life threatening injuries and delta was non life threatening injuries.

For me, it’s the bravos that made me nervous because those were the ones that could deteriorate quickly. I always felt like with alphas everyone came with their A-game ready to go but people tended to be a little relaxed with bravos because they were not as serious. I walked into the trauma bay and the trauma team had already cut off clothes and attached him to monitors. On the stretcher lay a elderly gentleman with white hair, he was awake and alert in no distress. Glancing up at the monitors, I noted a good blood pressure, heart rate was 106 and his oxygen saturation was 94%. Mr. Stork, I said peering at his name band. My name is Dr. Matemavi I am the chief resident and we will take good care of you, I leaned over touching his shoulder. What’s the story? I asked Lisa, one of the paramedic who had brought him in. I had known her for the last couple of years as we met in the trauma bay often in the middle of the night. Lisa had that no nonsense attitude about her, I liked her.

Elderly gentleman on Coumadin for atrial fibrillation, fell down a flight of stairs. Vitals have been stable en route, he is complaining of left sided chest pain, abdominal pain as well as back pain. History of coronary artery disease status post CABGx3, hypertension, hyperlipidemia. He lives at home with his wife and is independent in all his activities of daily living.

Haemothorax_Erect_-close_upAs a chief resident my job was to oversee and orchestrate, the best place to stand was at the foot of the stretcher where I could see everything that was going on. The nurse had placed a 16 gauge IV in the right antecubital fossa and the intern had placed another one on the left and 2 bags of crystalloid were infusing through his veins. Activate massive transfusion protocol please, I said to the intern in black scrubs. I looked up at the fourth year resident and gave a sign to get ready to place a chest tube on the left and turned my attention to the third year resident who was doing the physical exam. ABCs are intact, left chest wall tenderness, LUQ tenderness, and right groin tenderness, he said as he continued his exam from head to toe. The patient was rolled to the side and he continued his exam palpating for fractures. Thoracic and lumbar spine tenderness, no step offs, good rectal tone, no blood. 

The X-ray tech placed a plate under his chest and Mr. Stork was rolled back on. Everyone scattered as he shouted, X-ray.. Shortly after, everyone came back and Mr. Stork was rolled again to place a plate under his pelvis for an X-ray. Soon after he was rolled back, his oxygen saturation fell to 81%. I looked at the ED  attending and resident who were at the head of the bed and gave a sign to intubate and the 4th year resident was readying to place a chest tube. Before going to look at the X-rays, I leaned over and said, Mr Stork, we are going to have to put a tube in your throat to help you with breathing and we will need to put a tube in your chest to drain the blood that is accumulating from your rib fractures. We will take very good care of you. I tied the sheet on the bed around his waist and stepped away to take a look at the images. As I expected, he had multiple rib fractures on the left (I counted 7) and a pulmonary contusion. He also had right inferior and superior pubic rami fractures on the pelvic X-ray which explained his groin tenderness.

The intubation was smooth as was the chest tube insertion. He was stable so I opted to take him for CT of the chest, abdomen and pelvis. As we were preparing to go to CT I called the operating room and asked them to get a room ready and by then my attending who had been finishing a procedure in the ICU had come down. If he had been unstable, we would have gone straight to the OR but in this case I wanted to have an idea of what it was we were dealing with. We stood behind the glass window and watched as the patient was pulled into the CT machine and back out. The intern in black’s job was to keep his eyes on the monitor at all times incase the patient’s vitals changed. I reviewed the images while the patient was being transported back to the stretcher and instructed the team to head to the operating room. There was fluid around the spleen and liver and there was air in the mesenteric vessels. I worried about a hepatic, splenic and bowel injury. I informed the OR that we were en route. His wife and daughter met us as we were rolling into the operating room. I assured them that we would take good care of him before disappearing  through the OR doors.

orAs soon as we transferred him to the operating room table, the beep beep of the cardiac machine slowed and there was a pause. I immediately checked for a carotid pulse and there was none. All I could think of was that I had told him and his family that we would take good care of him. I immediately began to do chest compressions, asking for the operating room table to be lowered. My attending placed a chest tube in seconds on the right and after 2 rounds of epinephrine and vasopressin, his heart began to beat again. I immediately prepped his neck and placed a cordis in the right internal jugular vein. At this point I was fired up on adrenaline. He was prepped from chin to thighs and drapped quickly. I left the OR to wash my hands before being gowned and gloved. With a towel clip on either side of the abdomen we lifted up on the abdominal wall and I made an incision from xyphoid to pubis and we were in the abdomen in 3 swift strokes. That was exactly how he had taught me to do it, the last 5 trauma laparotomies we had done together in the last month. We drained a liter of blood and then immediately packed lap pads into all 4 quadrants. I looked up at anesthesia and asked if they needed time to catch up with blood products or if we were ok to proceed. The anesthesiologist nodded  for us to proceed. Same anesthesiologist we had worked with our last 3 traumas. I was beginning to think the combination of him, my attending, the fourth year resident on call and I was a lethal one. We always got bad cases.

One by one we removed the lap pads, carefully looking to see if there was blood welling laparoup. The right lower quadrant was dry as was the left lower quadrant and right upper quadrant. We focused our attention in the left upper quadrant were blood was soaking the lap pads. The spleen was lacerated and bleeding profusely. I had never done a trauma splenectomy before or seen one. My teacher got control of the splenic vessels as I worked to keep the field dry and within a few minutes the spleen was out. The bleeding subsided but was still there. We packed the left upper quadrant and put an Abthera vac on before taking the patient up to the SICU for further resuscitation. He was oozing everywhere because he was coagulopathic. He had the trifactor of death; cold, acidotic and coagulopathic.

When we arrived in the unit we placed a Swan-Ganz catheter and did an echo which showed elevated PA pressures, dilated right ventricle with right ventricular hypokinesis and EF of 20%. We continued to resuscitate with blood products and factors. He continued to deteriorate becoming hemodynamically unstable requiring multiple pressors. As I stood at the foot of the bed defeated, I felt a soft touch on my elbow and I turned around to find his daughter beside me with his wife next to her. I don’t know how long they had been standing there. She whispered softly, “It’s ok, we know you did the best you could, it’s ok to let him go.” For the first time I allowed myself to feel, I had been operating like a robot, focused on keeping this husband, father, grandfather, alive with the hopes of being able to rehabilitate him to his baseline during his stay with us. After all, we are surgeons; that’s what we do. Help those who are sick, injured and vulnerable and get them back to their usual state of health, whatever that may be.

compassionTears escaped, despite all my efforts to keep them at bay. The daughter who was in her late fifties embraced me and comforted me. True compassion. She was in the midst of losing her father unexpectedly, who she had enjoyed a round of golf with that day; but she looked past her own pain and took the time to comfort me. The family requested that we keep him alive until all his family who lived in town had arrived to say goodbye. He died peacefully, surrounded by his family. That morning as I drove home, I keep thinking about that family. My job is emotionally draining and I have a graveyard in the recess of my mind where all my patients that I have lost are buried. This goes back to the time I was a nurse. It’s a difficult part of the job and as a physician you can not let it affect your performance. Shortly after he died another trauma was called overhead and I had to pull myself together and give my all to my next patient.

For me losing a patient never gets easier. I cope better but it still hits me very hard and I cry every time. It’s hard when as a surgeon somehow we are trained to be ‘tough’ and not show emotions. I feel for my patients and I feel for their families. Every time we do a compassionate extubation, I think of that dreadful day when my family and I sat around my mother’s bed when she was compassionately extubated. It was not until then that I truly understood the impact it has on families. We had an amazing intensivist and she made the whole process bearable for us. When we have done all that we can and there is nothing more to do, my focus is always to make sure my patients are comfortable and never alone.

**Names and details changed to protect patient confidentiality.

sky-beautiful

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