by Jim Goodnight
“A guy’s been brought in with a major stab wound to his abdomen. He’s in profound shock. We’re on our way to the OR.” Sherwood, my chief resident knew what to do to get rescue underway. He’d earned the respect, but neither of us knew what we would find or whether we could fix it. I grabbed my keys and raced to my car.
Besides the victim oozing life, being a newbie weighed heavily on my mind as I sped down the freeway. Just hired as assistant professor at UC Davis taking my first turn on trauma call. Eyes were on me. My boss and new colleagues had been busy forging a first class trauma center. Like all general surgery faculty I covered trauma call in rotation, even though I specialized in cancer surgery. Years of training doing my share of trauma surgery made it okay. The difference on this hot Saturday night in August 1980, I was in charge for the first time. The peer pressure felt intense.
At the hospital, I hurriedly changed into greens and scrubbed rapidly. The nurses rushed me into gown and gloves. Sherwood looked up, “Boy am I glad to see you. Whoever stabbed this man wanted him dead. The knife must have been huge. It went through his spleen and deep into his liver.” The blood covering Sherwood’s gown plus our anesthesiologist’s urgent calls to the blood bank said enough. No need to ask “How bad?”
The difference on this hot Saturday night in August 1980, I was in charge for the first time. The peer pressure felt intense.
I waded in. The deluge of blood complicated systematic assessment. We quickly removed the spleen to control that source of hemorrhage. The worst bleeding came from a large rent near the top of the liver. Clamping off blood flow to the liver reduced the bleeding slightly. Packing the rent provided brief but only temporary respite. Any attempt on our part to expose the bleeding points for repair made the hemorrhage worse. A tone of dread crept into our terse verbal exchanges.
Sherwood and I struggled to see anything through the sticky, red veil flowing everywhere. Behind me, I heard Lea the circulating nurse answer the phone. “Really, you have to? They’re in a mess!” She interrupted us. “I’m sorry! Your resident in the Emergency Room insists he speak to you.”
Lea held the phone to my ear. Tom the resident, young but battle-trained, quickly described a teenager stabbed in the abdomen. “He’s stable, but bowel is protruding through the wound.”
In the fewest words possible I growled, “Get him to the Operating Room. Get ready to open. I will try to find you some help.” I had to trust Tom to function at the top of his game. No way could I leave to assist.
We were losing our battle. I said to Sherwood, “I think he’s bleeding from the inferior vena cava where it crosses the diaphragm.” Sherwood nodded. I imagined the grim expression behind his mask. In this narrow space, large veins from the liver enter the vena cava. A half inch away just on the other side of the diaphragm is the right atrium of the heart. Blood flow in this spot resembles Niagara. Exposure of the area requires dissecting the liver off the vena cava, a maneuver not really feasible amidst the bleeding and tissue damage.
As Sherwood and I fired possible solutions back and forth, the Emergency Room phoned again. Lea’s “Oh no” said it all. A gunshot victim had just arrived in shock. His wound was low in the left abdomen, the trajectory indicating injury and bleeding in the left side of the pelvis. Hemingway’s tales of Spain flashed in my mind. The horn of a bull piercing the big iliac vessels lying there in the pelvis is what kills toreadors.
In the midst of such chaos, time to worry is absent. Just act! With help from Lea, I phoned the vascular surgeon on call and asked, perhaps more pleaded, for him to come in. The grim urgency of the situation charitably expanded my authority. Seb responded immediately, “I’m on my way!” Amazingly, the Operating Room staff found another crew to set up a third room.
We kept desperately working on our man. Controlling and repairing the ragged hole in the vena cava necessitated clamping the big vessel above and below the injury. Limited access to this area puts any such maneuver in the realm of wishful thinking. Moreover, clamping off the inferior vena cava greatly reduces return blood flow to the heart. Our man’s already low blood pressure would plummet.
I felt sad and deflated over the loss of John Doe 3 but reasonably reassured we had done our best under dire circumstance.
Sherwood asked, “What about a Gott Shunt?” Potentially, passing a large tube down through the right atrium of the heart into the vena cava below the liver creates a shunt for blood return to the heart. Passing loops around the big vessel to compress it against the tube inside makes possible isolation of the injured segment. Describing this maneuver is awkward. Performing it is even trickier and unfortunately it rarely works, but our options were exhausted.
As we readied the tube and prepared to open our man’s chest to reach his right atrium, the massive blood loss defeated us. His heart stopped. We couldn’t resuscitate him. We didn’t even know his name. In the emergency rush he was identified as John Doe 3 (third John Doe of the day). His death became a police matter. I never learned his real name nor met any relatives. This terribly impersonal circumstance further dehumanized the grim tragedy. We could comfort no one. I left Sherwood to close the wounds and went to see about the other cases.
Tom had the second stabbing victim’s wound under control. He had repaired a small injury to the bowel, found no other damage and was ready to close. Hopefully the wounded teenager would find a happier path in life henceforth. I went down the hall to check on the gunshot victim, his injury apparently a crime of passion. Seb had isolated the left iliac artery, controlled the bleeding and was busily repairing the damaged vessel. The patient would live but I had serious doubts about survival of his domestic relationship. I returned to help Sherwood finish.
I felt sad and deflated over the loss of John Doe 3 but reasonably reassured we had done our best under dire circumstance. I also thought, “This is about as much fun as a rubber crutch, but I can do it. I can handle this mayhem.” The rest of that first night on trauma call was quiet. I never experienced another just like it.
Days later at Morbidity & Mortality conference, my new colleagues thoroughly discussed our man’s fatal injury concluding that we had probably done our best. Over the ensuing years, all of us became steadily more adept at managing these big liver injuries. With such massive hemorrhage and shock, the patient becomes hypothermic which greatly inhibits blood clotting plus essential clotting factors are lost. We learned to do “damage control” surgery. The idea is to pack the injuries as tightly as possible, close the abdomen, and continue resuscitation. Damage control may provide time to reverse shock, warm the patient and replace clotting factors before returning to the Operating Room to do necessary repairs. As you might imagine, each time we discussed such cases, my thoughts drifted to Sherwood and me on that hot August night.