Wednesday, September 4, 2013

Day 6: Get used to the feeling.

Barring an organ procurement where it is obviously expected, I have never had a patient die on the table in the operating room before yesterday. I was told to get used to the feeling.

A man in his mid-twenties was involved in a motorcycle accident. Not sure what time, not totally sure of the mechanism. Some reports said that he was hit by a car. Came into the Emergency Room, and the General Practitioners there gave him about 1.5 liters of fluid. Think he got blood as well, but not sure. When I came into the ED at 7am, an American ER physician was just taking over his care. They were trying to intubate. No blood pressure, had a carotid pulse, but no others, and couldn't get an O2 saturation. He had a massive injury to his perineum that he was exsanguinating from. No other large injuries. The ED docs got him intubated, and soon after we lost pulses, and had to start CPR. Pushed epinephrine, the only drug we have in a code, it seems. Worked though, we got him back that time. We took him to the OR as fast as we could.

Got him on the OR table, and he coded again. More chest compressions, more epinephrine, more volume given. We now have blood available, and he gets it. Get his legs up in stirrups so we could access this perineal injury. Trauma ex-lap found only a large retroperitoneal hematoma that was extending from his pelvis all the way to the SMA. Turned our attention to the still-bleeding large hole in the man's perineum. It is approximately 5 inches, right next to the anus, and a steady stream of blood is pouring out despite the packs we put in there and my hand holding pressure. Rectal wall has been sheared off to the mucosa, but not fully penetrated. The hole extends into the pelvic retroperitoneum and the sacral plexus of vessels is bleeding. Try to cauterize what we can, try to tie off what we can, decide to pack and get out of there as quick as possible. We intraperitoneally pack the pelvis, pack the wound, and close skin on both sites.

Anesthesia can't find pulses. PEA arrest. Two rounds of chest compressions, epinephrine. Nothing. We keep going. Nothing. Twenty minutes later we call it.

Oh, and a two-year old kid with 50% of his body surface area burned who is on our service died the night before. Probably pneumonia.

Went to bed fairly early last night. Got to get up now and get back in the game. It's 4:30 am.

I've decided to not let myself get used to that particular feeling.

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