Last Tuesday was probably the defining moment in my surgical career. This was the moment that I always knew would come. I would be all alone, and have people's lives in my hands. Where there is no senior staff around to call for help. Either I did the job or the person dies, simples as that.
It started off with a ANA (Afghan National Army) soldier who was hit by an IED and came in confused and combative, his blood pressure was good but his heart rate was too high. We intubated him to control his airway and keep him from fighting us. All of his injuries appeared superficial, but I suspected a head injury and his heart rate was still too high. I put him in the ICU to watch him because more patients were coming.
The next wave of patients came with 3 US soldiers after being hit with an IED. Their MRAP (Mine Resistant Armored Personal Carrier) was hit by an IED and rolled over down an embankment. Two of the three were fine and just need CT scans of their heads. The third though was in dire straits. On ultra sound he had blood in his abdomen and his blood pressure was real low. We gave him some volume and rushed him to the next room, the operating room. After opening his abdomen, there was a lot of blood. He cracked his spleen in half, had a liver laceration, fractured pelvis and dislocated hip. I took his spleen out and packed his abdomen with sponges to provide pressure to stop the bleeding in his liver and pelvis. Just about this time the first guy, previously described drops his blood pressure, pushing my hand to take him to the operating room. I take my current patient on the table, put a vacuum dressing on his abdomen, essentially leaving him open and intubated to the ICU to get him warmed and resuscitated.
I rush the first guy from the ICU to the OR and open his abdomen where I find another large liver laceration and small hematomas around the blood supple to his bowel. These were not getting any bigger so I decide to leave them alone. Just then, I hear a rattling "WHAM" outside the tent. The "incoming fire" sirens going off! Some where, someone fired a 107mm rocket that landed about 50 yards from our FST tent, thankfully on the other side of a barrier. I send my assistant to the bunker and my CRNA, tech and I plow a head. We pack his abdomen open and as we are getting him off the table we get reports of wounded from the rocket attack.
Two patients, each peppered with fragment wounds along their legs and arms. One guy is fine, the other guy is alert and awake, but he has a tense lower left leg and no pulse in his foot. I take him to the OR to release the hematoma in his calf, thinking that it may be compressing his arteries to the leg. After the release, still no flow to the foot. No I am thinking, arterial injury. As I prep to do and angiogram, he starts squirting blood from the frag hole. Game on! I expose the above knee popliteal artery to get proximal control and stop the bleeding, then get into the injury and sure enough the below knee popliteal artery has a big side wall injury. I ligate the injured and bleeding vein and place an intra-luminal shunt (kind of like a silicone straw) in the injured artery to keep blood flowing to the leg and stop the bleeding.
WOW! What a day. I sent all three patients to Bagram for further care, and from what I have been told, all three are doing very well. I went to sleep that night with a big smile on my face. This is what I have spent the last 10 years of my life, culminating to this point. I said many prayers during those surgeries that day, and all were answered.
Wow. That is just amazing. It is really something to find out that you have what it takes when things are going south.
ReplyDeleteI haven't had anything close to what you describe happen to me, but a couple of weeks ago we had a guy bleeding badly from a tumor which had taken over just about all of his tongue and the front of his neck. This was about 3AM and we had to secure an immediate airway as he was pouring blood out of his mouth. The anesthesia guys couldn't get a tube in (fiberoptic through the nose) and after a bunch of attempts the attending anesthesiologist handed me the bronchoscope and said "I can't get it." My attending (a sinus guy who doesnt deal with this stuff) said "I sure hope you can get this." I looked back and said "I will get this tube in" -- and I put that sucker in. Although my knees were a little weak afterwards, I was the last line between this guy surviving the next 10 minutes or not and I was able to get the job done. Again, it's nothing like your experiences, but I can relate just a bit.
Consider that you have been in country for less than a month. When you get finished there, there will be no challenge too difficult for you to handle. You will have that elusive, but golden physician quality of aequanimitas William Osler spoke about and you will bring presence and calm to those around you.
Good job, and thanks for your service.
Many of my friends talk about those defining moments in a young surgeons life where you discover something about yourself. Something that you know is there, trained into you, but still undiscovered. I think that this is a process, but a big step none the less.
ReplyDeleteNext blog will be about a facial trauma case.... OOoooo, the suspense.
The consult line is always available. ;-)
ReplyDeleteFrom Ostler "Aequanimitas"...
"In the first place, in the physician or surgeon no quality takes rank with imperturbability... [which] means coolness and presence of mind under all circumstances, calmness amidst storm, clearness of judgments in moments of grave peril, immobility, impassiveness, or, to use an old and expressive word, phlegm (an ENT favorite). It is the quality which is most appreciated by the laity though often misunderstood by them, and the physician who has the misfortune to be without it, who betrays indecision and worry, and who shows that he is flustered and flurried in ordinary emergencies, loses rapidly the confidence of his patients.
... Even under the most serious circumstances, the physician or surgeon who allows 'his outward action to demonstrate the native act and figure of his heart in complement extern,' who shows in his face the slightest alteration, expressive of anxiety or fear, has not his medullary centres under the highest control, and is liable to disaster at any moment."
You guys are so cool it hurts (but like, in a good way. Not in a lacerated liver kind of way.) :)
ReplyDeleteWe are incredibly proud of both you guys and the great work you do. It is very sacred, this business of physical ministry, and I know you will always have the Lord guiding your hands. Somebody was there binding the wounds of the Stripling Warriors.
ReplyDeletewow, a very different world than what I am living in...good work.
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