I ran my first trauma the other day. My intern and I met down at the trauma bay in the emergency department for a patient that was found down by the side of the road next to his car. No eyewitnesses. He was intubated at the scene for respiratory distress, the medics thought he had a sucking chest wound. (he didn’t, but it was a good call none-the-less). Prior to the patient’s arrival, we had the chest tube kit out and ready.
When he arrived, his blood pressure was about 110 systolic (low normal). As we descended upon his sedated and paralyzed body, each team member began their own checklist of tasks. The respiratory therapist connected his tube to the ventilator. The emergency room resident checked the patients head, eyes and the position of the tube. The nurses began a 2nd IV line. My intern (after some prodding from our attending), drew blood from the femoral artery. I was supposed to be running the resucitation…but didn’t know what to do next. It seemed to be running itself, with everyone attending to their tasks. Activity slowed and the trauma surgeon turns to me, “What do you want to do next, doctor?” “Let’s roll him and check his back.” I received a nod of encouragement from the emergency medicine resident at the patient’s head. We examined his back.
The ‘sucking chest wound’ turned out to be just a chest wound, but a bad one. His entire left back collapsed asynchronously with the ventilator. His ribs were mush. He had a large bleeding avulsion of his skin about six inches across by four inches wide, connected on one side by a flap of skin about 1/4″ thick. His blood pressure was now 95 (getting worrisome). “Give him some more fluids,” I shouted to the nurse across the room. She ignored me. “Is that bag of saline wide open,” I shouted. Yes, it was…dripping about once every second, far too slowly to help a blood pressure of 95. The nurses were ahead of me, trying to start a second, larger IV line. “What do you want to do next?” the surgeon asked me again. My mind was frozen. His blood pressure was getting lower. I knew that all trauma patients needed a foley catheter placed at some point. “Let’s get the foley in.” I ordered the intern. Six sets of eyes turned and looked at me. “Do you want to get x-rays first?” the attending asked. “Yes, that’s a great idea, let’s get the x-rays first,” I repeated after him, hoping to engrain the proper order in my visceral memory. Those chapters I studied earlier were doing me no good right now.
The x-ray team came in and shot the standard trauma series. I looked at his blood pressure again, it was now 75. (getting dangerously low). I shouted his pressure out loud so the room could hear. Thankfully, the attending took over at this critical moment because I was really stuck. “Let’s get that chest tube in.”
I grabbed the tray, ripped open the kit and began prepping the patient’s side. I took the scalpel, felt for the right rib space. A little voice was over my shoulder…why don’t you put some drapes on…it suggested to me. I shouted for drapes and finished the sterile prep. I cut down to bone on the first attempt and grabbed the smaller pair of hemostats. Why don’t you use the Kelly’s the voice said. I grabbed the Kelly clamps and thrust them into the patients side. He was so thin, I didn’t have to disect too far to reach the intercostal muscles. The moment of truth had arrived…I braced my index finger about an inch from the end of the clamps as a stopper to keep me from punching right through his lung. I levered the tip of the Kelly’s over the top of his fourth rib and pressed…and popped…right into his chest wall. Air rushed out. I opened the clamps inside his chest wall and bluntly tore the intercostal muscles to make room for my tube. The tube slid easily through the opening and slid along the back side of his chest cavity where it would act as a drain for the blood that was collecting in his chest, as well as letting the air escape from his injured lung instead of compressing his lung further. I sewed the skin together tightly securing the tube in place and connected it to suction. The patient’s blood pressure climbed to 120…better than when he came in!
“You saved his life,” the attending surgeon calmly said, “How does it feel?”
I shouted out in the hallway for x-ray to repeat his chest film, numb that I had almost watched this man die as I stood helplessly not knowing what to do. I guess that’s what residency is for.