1am. Its a busy Friday night... wait, or is it Saturday night? I'm on nights this week and the days have begun to blur. Using an ultrasound machine I guide my needle into a juicy internal jugular vein and aspirate back dark blood. I drop the ultrasound probe from my right hand and pick up the guide wire to thread it through the back of the needle and into the vein. Moments later the procedure is done and a clean dressing is placed over the new central line which the nurses will now use to give medications, draw blood and measure the central venous pressure (CVP).
I step out of the patient's room and scan the ICU for an open computer. Before I get the chance to sit down I hear the overhead PA sound. I hold my breath. "Major Trauma Alert in 6 minutes, Major Trauma Alert in 6 minutes."My pulse quickens as the adrenaline is released into my bloodstream. I take the back stairwell and swiftly make my way to the trauma bay in the emergency department. The temperature in the bay is warm in order to accommodate patient's in shock that come in with lower body temps. I take off my jacket as I walk in and don protective eye wear and a facemask. I glance up at the board that gives the one-liner about the patient I am about to meet.Young male, automobile vs pedestrian, GCS 5 on the scene.For some context.. GCS stands for Glasgow Coma Scale. 3 is the worst and lowest number on the scale. 15 is the best. Theoretically, anything less than 8 buys you a breathing tube. He was a 5.Running a trauma involves performing an initial primary and secondary survey. A tertiary survey is typically performed the next day and its purpose is to catch any injuries missed during the initial encounter. The primary survey mainly consists of the ABCs. Airway. Breathing. Circulation.
I position myself near the head of the bed as the EMTs roll the patient into the room and begin to give report. He appears unresponsive. He is transferred onto the gurney and I begin with a strong sternal rub to see if I could rouse him. He eyes remain closed and no sound emanates from his mouth. However, he is able to briefly flex his right arm. GCS 5.From that interaction it is clear he is not protecting his Airway. We need to intubate! In moments like these a glide scope is often used to visualize the vocal cords to ensure the endotracheal tube goes into the trachea and not the esophagus. The breathing tube is placed easily, but its immediately clear that there is some blood coming upfrom the lungs.
Breathing.I take the stethoscope around my neck and place the drum on both sides of his chest. Diminished breath sounds. Given the nature of his accident I am not surprised he would have trauma to the chest. We need to place chest tubes! An incision is made between the 4 and 5 rib on both sides and a dissection is made down to the rib interspace. Using a blunt instrument a hole is made in the pleura to create a communication between the inside of the chest and the outside. I place a tube into the chest and connect it to a collecting box on the ground called a pleuravac. The same is done on the other side. Immediately the blood previously in his chest begins to drain into the collecting box.
I then turn my attention to Circulation. I feel for the femoral pulses in the groin and discover they are thready and weak. His heart rate is elevated, over 140 beats per minute! He needs blood. The skilled nurses in the emergency department descend on him. Sharpshooters, every single one. Within less than a minute they had several large bore IVs placed. We are ready to transfuse!I take a moment to breathe and look up at the monitor. Vitals look stable. Time for a quick head-to-toe secondary survey, chest x-ray and then off to the CT scanner.What we discover from the CT scan leads to an immediate decision to take the patient directly to the operating room! Active bleeding from the biggest vein in the body, the inferior vena cava (IVC), right where it drains the right and left common iliac veins. In the operating room a midline abdominal incision is made and the IVC exposed. A repair of the defect is performed and the surrounding structures examined to rule out injury.
During the case the patient began to have diffuse bleeding from his lungs. One of the other injuries suffered, discovered on the CT prior to heading to the OR was a laceration to the lower lobe of the right lung! The blood poured into the breathing tube and saturated both sides of the lungs. For a moment it appeared that the patient may drown in his own blood! Fortunately we were able to isolate the bleeding and place a bronchial blocker to protect the left lung until the bleeding subsided on the right!
The patient is taken back to the ICU and I head back down to the emergency department to find my jacket. It is only then that I am able to begin to process the events that had just transpired. I take my phone from my pocket and glance at the time. 530am. Saturday morning. I slip on my jacket, dip my hands in the pockets and head back upstairs to the ICU.
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