The trauma post

WARNING: This post is going to contain graphic descriptions and pictures (by clicking a link). This is merely a post to inform and somewhat vent about the contradictions of my life. There is some shock value in this post, but again, it is truly a representation of what my daily life is like.

So to begin, I need to give a little background. In residency, there are different teams of surgery residents that work together on a certain subset of patients. We call them services, and here at the med center we have 3: Trauma, General Surgery, and Cardiothoracic Surgery. I am currently the chief of the Trauma Service, meaning I am the highest level resident in charge, and am the one ultimately responsible for the decision-making on a resident level. The attending is the "boss" that is above me, whom I answer to, and ultimately is legally responsible for what we as residents do. Trauma is a 24/7 job--we never know when someone is going to get shot, stabbed, get in a wreck or do something else to try to kill themselves. We know that a trauma is about to arrive, or may have already arrived, when we hear overhead, "Trauma alert to the trauma room, trauma alert to the trauma room." We also get pages on our pagers. Then the entire trauma team, which includes residents on the trauma service, as well as respiratory therapists, nurses, and CRNAs, all go down to the trauma room to see what we got this time. This happens all hours of the day and night. That is why I rarely sleep much on call. A new report has come out recently showing that USA Med Center has a very high trauma acuity, like 49th in the country. That means that there are only 48 other hospitals in the whole country who get more and sicker trauma patients than we do.
All that to tell you about a trauma I had over the New Year Holiday, and how it affects my life (or doesn't I guess). We had a trauma alert, and go downstairs. When we get there we find out it's a gunshot wound (GSW) to the chest. This could be nothing, but it could be very bad. So the guy rolls in and he isn't intubated and doesn't have IV access--not good for him. We quickly get him intubated, and put in 2 cordises (very large IVs that are put in a central vein that you can give lots of stuff through very quickly). We then proceed to put in bilateral chest tubes to see if he is bleeding into his chest. He is. And BTW, he is in pulseless electrical activity (PEA), so we are doing CPR this whole time. So, he is bleeding from his left chest. Leads you to believe he may have an injury to his heart. The next step in the algorithm is to open his chest--right there in the ER. So we do. It's called an ER Thoracotomy, and how to do it is described in the trauma literature, so we all are well trained in this. We take a scalpel (we call it a knife) and cut him from sternum to as far down on the bed as we can go following along his ribs all the way down to bone and muscle, and then keep going, until you are looking at heart and lungs. Then you open the pericardium to relieve any tamponade (blood inside the pericardium that might be exerting pressure on the heart). He did have tamponade, and we evacuated a lot of blood. We then realized that he did have a bullet injury to his heart which we needed to repair very quickly if we were going to save him. So then we proceed to clamshell him. That is when you take the knife and do the same thing on the right side of the chest, so you have one big cut from one side to the other. One of my former attendings used to say that you could see the soul through this incision. The easiest way to complete this is to take a pair of trauma shears (really big scissors) and just cut through the sternum and the ribs on the right, which is what we did. Here is what it looks like. Next I sewed up the holes as best we could while my 3rd year resident was providing internal cardiac massage, which is like providing CPR, but better. Meanwhile, the nurses are trying to give him meds to help restart his heart, and lots of fluids and blood, because when you are doing this, most everything is already leaking out of the heart onto the floor. And here is what that looks like. This patient unfortunately did not survive, though hopefully you can tell that we worked really hard and did everything we could.
After this occurs, we leave the trauma bay for the cleaning staff to come in and clean up, go tell the family he didn't make it, and go on about our business, which for me means try to go get some sleep. Then I get up, hand off the pager to the next team, tell him that he missed a clamshell last night, and go home.
As I was telling my mom this story while I was on the way to the grocery store with Porter, I realized how really wierd this whole almost double life is. I do some really strange things at work every day, and then come home and am hopefully a normal mother. (No comments please ;) ) She is totally grossed out and horrified, but it doesn't really effect me at all. How am I going to explain this to my child one day, and how do you teach him to have respect for life and death when sometimes I seem to have none? And I wonder if it is ok to talk about moments like that in front of him. I imagine it has effects on adults, so how could it not have implications for children--they're so innocent. Just things I think about.....