November 30, 2016
Written by Katie Darfler (class of 2016-2017)
I arrived early and grabbed a corner spot in the room. Soon, as most everyone has noted, the sleepy residents began to trickle in. A doctor began lecture by proposing “something new.” [I did not get the doctor’s name, unfortunately, because he didn’t introduce himself before and he was busy discussing surgery cases after lecture.] He suggested proposing a trauma scenario and running through it in assessment and care with the residents. He told them that this would be helpful preparation for their boards, and it was really cool to be a part of.
The scenario was a thirty one year-old male in a high-speed MVC (motor vehicle collision). The patient’s vitals were: a systolic blood pressure of 90 (which, he noted, is an ambiguous blood pressure, so it is great practice for the boards) and a heart rate of 110. The leading doctor then cold called various residents to go through the steps to assess this patient in a trauma bay. The first resident claimed that they should assess the airway. To that, the doctor responded “yes” and told the resident that the patient had a GCS of 7. I remembered from pathophysiology that GCS is short for “Glasgow Coma Scale” and is noted as the most common scoring scale for determining a patient’s level of consciousness following potential brain injury (brainline.org). A patient’s GCS can be anywhere from 3-15. A patient receives a number for various subcategories of assessment: Eye opening (1-4), Verbal Response (1-5), Motor Response (1-6). Each number in the subcategories corresponds to the way a patient responds to a stimulus. Any GCS of 3-8 is considered a severe injury. To learn more, you can visit: http://www.brainline.org/content/2010/10/what-is-the-glasgow-coma-scale.html. So, I now know that this patient is considered to have a relatively low GCS. Okay, so back to the resident who decided to assess the airway. At this point, several other residents were chiming in with their own thoughts and ideas. One resident said “RSI!” which I now know is “Rapid Sequence Intubation.” I learned that RSI, a method that uses anesthesia, is the ideal method for endotracheal intubation for patients in the ED because it “results in rapid unconsciousness (induction) and neuromuscular blockade (paralysis)” (emedicine.medscape.com). After the lead doctor asked which drug they should use for RSI, one resident chimed in and suggested that they use etomidate, an anesthetic. The doctor then followed up and asked that drug’s adverse effects. Several residents said “adrenal insufficiency.” The residents seemed to all agree that they should not use propofol or ketamine for the RSI. At this point, the doctor asked about what types of paralytics the residents could push. Several residents said “polarizing or depolarizing.” Another resident suggested using “sux” (Suxamethonium chloride), apparently a short-acting paralytic.
The next step in assessment would be to assess bilateral chest sounds. Another resident chimed in that the next step after that would be to check circulation: central pulse, blood pressure, and access. At this point, the leading doctor asked about what size IV to use. One resident said that the largest bore IV possible is ideal, located in the ACs. At this point, the doctor asked what to do if a nurse brings a “triple lumen” IV. Everyone at the table seemed to know this was a big “no no” and responded that this particular IV should not be used. The doctor asked what to do if achieving a large bore IV was not possible in the ACs. The residents agreed that they should now try for a central line or go IO (intraosseous infusion). If they had to go IO, they would try for the sternum, the humerus (ideal), or the tibia. The doctor asked, “What next?” and one resident responded, “Give blood.” All agreed to begin O negative blood because, as the lead doctor suggested, a main reason for hypotension in trauma is loss of blood.
The residents continued their primary survey and then decided to get a chest x-ray and a FAST, especially because he was involved in a blunt trauma from the MCV. The FAST is short for “focused assessment with sonography for trauma,” and basically means a rapid bedside ultrasound that looks for blood around the heart (pericardial effusion) or trauma to abdominal organs. Then, the residents decided to move into the secondary survey. They found that the man’s pelvis was unstable. After several suggestions about using a pelvic binder to “compress form to tampenade venous bleeding,” there was a short debate about binder efficacy. Another doctor in the room suggested that all orthopedic literature suggests binders for all pelvic fractures. They called this type of binder a “T pod” and discussed proper placement on the greater trochanter for greatest effect. The next resident suggested to do a PAN scan. The doctor then said that the patient’s blood pressure is decreasing and asked what to do. A resident suggested giving more blood. The lead doctor agreed and insisted on not using “crystal light.” (I could have sworn this was a sweet drink found in vending machines, but I think that is what they said!) The doctor said whole blood is best (with a 1:1:1 ratio of RBC, platelets, and (I believe), clotting factors). The residents then suggested repeating FAST, looking for pelvic bleeding, activating DPA, and then potentially ligating the internal ileac vein bifurcation. (Things were moving very quickly at this point, and I was trying to keep up with notes!) The doctor then discussed REBOA, a method that replaces an aortic cross clamp by putting a balloon in the aorta and occluding distal bleeding. However, apparently this procedure takes a while and would not be ideal for an immediate trauma.
Surgery 1: OR3, Abdominal Ex. Lap. Fascial Closure, Dr. Sadjadi
I arrived in OR3 to see a patient on the table with most of his small intestine visibly exposed. A sweet doctor came in and explained what was going on with this patient. He said he’d been stabbed and had significant damage to his liver. He had already had one round of surgery, but explained that the patient would likely need several more to get his “guts” back in and close the wound. Basically, in the crudest of terms, the surgery was attempting to push the exposed organs back in and sew the man’s abdomen up partially. I was eagerly welcomed to view the surgery and everyone was very friendly. I was really impressed with how all the doctors approached the surgery with such humility. They asked questions of each other and talked about decisions being made, all without a hint of ego. One doctor asked if the other was going to excise the liver. The lead surgeon said that he would not because the liver was mostly dead and he was worried about bleeding. With the help of a resident, Dr. Sadjadi made stitches in the fascia, alternating the top and bottom of the approximately foot-long opening. It was almost like a corset closing, but the organs inside were so inflamed, so it was not possible to fully sew the man up. One resident worked to push the organs back in while Dr. Sadjadi continued his stitches. At this point, the team took out the rag that was covering the organs and put in a plastic sheet, then covered that with wet gauze, and then covered with something called an “ioban” sheet, which I assume is to keep the area as clean as possible. One doctor asked Dr. Sadjadi how he knew if the skin was close-able. Dr. Sadjadi said it is a lot about how the skin feels, its turgor. The surgery was relatively quick, from 8:23-9:02. On the way out, Sarah Bradford, a kind resident, took me under her wing and allowed me to follow her into the next surgery, which was already underway.
Surgery 2: OR6, Female ejected from vehicle, two broken legs, one dislocated right knee, questionable pulse in right foot (potentially from an occluded popliteal artery)
Dr. Bradford helped me put on my “leads” because there were many x-rays occurring in this patient’s room and we needed to protect our bodies from radiation. The first thing I noticed when I walked in was a doctor literally power-tool drilling into this patient’s femur. I learned that these drills would be essential in setting up the “external fixation system” (shown below) that would stabilize this woman’s bones, which had been broken in multiple places.
Throughout the drill process, an x-ray technician took multiple shots of the bones in her legs and her knee. She had dislocated her knee in such a way that many of the doctors said they had never seen before. Apparently, the dislocation not only tore her ligaments, which is to be expected, but it also sheared off the top of her tibia (I think). The doctors were concerned about this because it would affect her cartilage as well, and lead to a long recovery.
Interestingly, the woman came in with what I understood to be a weak or absent pulse in the foot. I learned that bones must be realigned or vasculature can be occluded, so that’s why the doctor was working on the bones before addressing the vasculature. I think, from what I understand, realigning the knee helped the pulse come back in the foot. The doctors used a doppler machine to find the pulse in the foot.
While this was occurring, a few people were working on closing up gashes on the woman’s head and forehead and shin. I watched them irrigate and prepare for suturing. I also got to watch them close up the gashes. As I listened to some doctors discuss her forehead wound, they mentioned that she would likely have a large scar. Apparently, when she got in her accident, she hit her head in a way that removed a big chunk of tissue, so it would be difficult to close the tissue (1), and it would heal in a way that went against natural collagen fibers (2).
This lady has a long road ahead of her, which made me feel sad, but I realized that all of these people were helping her take that first step. It was really an honor to be a part of the day.