Wednesday, August 02, 2006

It was bound to happen sooner or later...

Last night I was on call at [large hospital]. My trauma beeper went off around 2315 saying "Code 3 LF ETA 15 18 yo M MVC extrication Int G3 S76 P164", telling me that a code 3 (serious trauma) was arriving by helicopter in approximately 15 minutes; the patient was an 18 year old male who was in a car accident, had a prolonged extrication from his vehicle, was intubated, had a coma score of 3 (on par with a cadaver), with a low blood pressure and high pulse. Oh, boy. I happened to be in the OR at the time, watching the vascular surgeon repair a bleeding arterial leg wound. The upper and lower level residents and myself rolled on the trauma.

I enjoyed the sound of my clogs on the hard floor, marching purposefully toward the ER. When I got there, I took off my white coat, put on a lead apron, topped it with a clean gown, put my stethoscope around my neck and got my trauma shears ready. I usually do this quickly, because the ETA's on the beeper are horribly inaccurate. Once dressed and ready, I sat on a stretcher and shot the shit with the residents and nurses. Since this one was serious, 2 respiratory therapists were there with a ventilator; an ER doc was there with the ultrasound to perform the FAST (a quick check for abdominal bleeding); 2 X-ray techs were standing by with the X-ray machine and multiple blank films; several EMT students were hanging around, hoping to glean some experience; at least 3 nurses were in the room ready, with others waiting outside the shock room door. After all the fuss, we sat around for 10, maybe 15 minutes, just kicking our heels in the air, ready to go.

It's almost an electric current in the air when the stretcher appears. Everyone leaped to the ready as the helicopter crew wheeled in the patient. They transferred him to the trauma stretcher and things started to fly. The helicopter crew was hollering out the history and vitals as the residents and attending physicians started the ABC's: Airway, Breathing, Circulation, the primary survey. "Patient was questionably restrained, driver, his car was T-boned by a large truck/semi on the passenger side." The RT's began to establish a better airway and hooked him up to the ventilator, multitudes of lines and BP cuffs and EKG monitors and pulse oximeters were attached, a Foley was placed, IV's and central lines were started, and an oral-gastric tube was passed to decompress the stomach. The ABC's work like slightly sticky but well-worn machinery: everyone has a job, and they do it, but it's noisy as hell, and there's the occasional tripping over used syringes (not needles!) on the floor or the curse as yet another IV infiltrates. I mostly hung back after cutting off his undies, noting how thin he was, how small, how young, how helpless.

His blood pressures started to drop, so we started running in blood alongside the fluids. Multiple X-rays were obtained, showing large pneumothoraces on both sides, so the resident and the attending each placed a chest tube. Blood started coming out of his mouth and OG tubes, so suction was applied. Xray techs were frantic, the FAST doc was frantic, the resident was hurrying to place a subclavian central line, and I tried to stay out of the way, yet be available to run errands (a pair of sterile gloves, some gauze, some tegaderm, a chest tube kit). The FAST was negative, yet his pressures continued to drop, stabilized only momentarily by the addition of more blood and fluids. CT scan or belly washout? wondered the attending. He opted for belly washout, which is how I found myself going from holding a liter of lactated ringer's solution over my head to crouching on the floor to let the belly fluid drain back in. We got his BP up to 100 systolic and decided to take him to the CT scanner, which was next door. We added a body-warming device because his temperature dropped to 94. Sometime while waiting to go to CT, the resident noticed that the patient's pupils had become bilaterally dilated and fixed, or "blown"--a sign of serious neurological injury, possibly fatal. He put out over 1/4 a liter of fluid out of his chest tube in about 30 minutes, all of it blood. He also continued to bleed out of his mouth, sucking blood in and out of his ventilation tube every time they bagged him on the way to CT.

In the scanner, his pressures dropped into the 70's again, and we opted to leave off some of the less pertinent exams and just get the basics: CT head, CT chest/abdomen/pelvis. The head CT showed diffuse subarachnoid hemorrhage, intraparenchymal hemorrhage and edema, and possible uncal herniation (hence the blown pupils and continued coma scale of 3). We grabbed all the IV's, the ventilator, the warmer, and the O2, and wheeled him back to his room.

I think it was on arrival back in the shock room that I began to notice the steady trickle. I wasn't fighting the EMT students for a position anymore, I wasn't tripping over the Xray techs anymore, nurses were no longer yelling at me to get out of the way. The room was clearing out; we were down to 6-7 people. The blown pupils had sounded a warning note, but the CT ushered in the next movement. Neurology said there was nothing to do. He also had less than 1/2 his lung capacity open due to massive pulmonary contusion and hemorrhage. Once back in the shock room, he failed to oxygenate on the mechanical ventilator, and had to be continuously bagged. He'd received 8 units each of red blood cells and plasma. The attending went out to talk to the family; I heard at least one person suggest "kidney donor?" I frantically wiped his face down with alcohol swabs and towels, because the family came in to see him shortly thereafter. We had covered up most of the tubes and lines, we'd cleaned her face, but there was no disguising the bag-mask ventilation, the blood bubbling up the bag, the tear-stained eyelashes, or the utter silence from the one person in the room who we wanted to make noise. Her daddy told him he would pray for him and they left, silent, dry-eyed. We rushed him up to the trauma ICU, where they continued to ventilate by bag.

Up in the ICU, the acting chief resident came up with some wild plans: since he had no clotting capability left, order factor VII to correct the coags, then neuro would see her again. Put him on a special ventilator to force O2 into her lungs. Keep bagging as long as possible if the special vent didn't work. The residents and nurses in the ICU looked at him in disbelief. "For real?" one asked. "He's got blown pupils, no movements, no reflexes, and you want us to do what?" The chief took no for an answer, so the staff got to work. Walking away, the chief said "He's going to die."

I went to the cafeteria with the residents after leaving the ICU. I ate a Mrs. Bairds cinnamon roll and tried not to cry in front of them. Then I went to my call room, got into bed, and couldn't sleep. Were they still bagging? How long would his parents keep it up? Was it possible he'd recover? I would think, what a waste of effort, and then I'd be so ashamed. What if it was my daughter or son? I'd want extravagant measures taken before I was told it was over. However, I couldn't help but feel it was a waste of many things. I also couldn't get the sight of his youth out of my mind, his strength and delicacy. What a waste of a life, and it wasn't his fault.

At morning report today, we were told the patient "expired". His family decided to withdraw care. Officially, he is my first patient that has died.

I didn't cry until I got home.


Allison said...

wow. i even cried at that. thanks.

Daniel said...

Perhaps not the best moment or method to contact you by, but I was catching up on your blogger and wanted desperately to say something.

I hope all your days you have the strength and courage and sheer determination it takes to face these kinds of things and fight for the lives of the tragic and the stupid.

I apologize again for the dissappointments I've caused you and though I'm a poor friend in acting on it, I think of you and Justin often and love you both and am very excited for both of your amazing careers and life together.


basia said...

we had a surgery canceled due to blown pupils. the next morning the intern told me she was "not with us anymore." i had to ask if they ment not on our service/list or not alive. Unfortunatly my patient suffered the same fate as yours.

Anonymous said...

Two "first patient death" stories in the same Grand Rounds is almost too much for me. The same comment I left on the other blog is appropriate:


My first patient death is coming soon, it's only a matter of when.

Getting a little wet at the eyes reading your story makes me dread when mine inevitably unfolds.

dr. nic said...

Your story reminds me of one from my 4th year rotation through the Trauma ICU at our local Level I trauma center.

My patient was also 16 and "accidentally" shot by her boyfriend in the back with a deer slug. She was airlifted in and when they got her on the OR table there was literally no blood in her heart. The bullet had removed the lower lobe of her right lung and fractured her liver. They got her back and brought her to us. Three days later when I was on call again we coded her 4 times before the family said enough. She was not my first patient to die, but she is one of the one's I'll never forget.

Kim said...

They'll always get to you, but the young ones will be the worst.

If it ever stops affecting you, it will be time to worry....

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