Another night at the county hospital and more adrenaline packed adventures..
A patient is rolled into the ICU, alarms going off on the monitor. His blood pressure reading 230/140 on the non-invasive cuff. He has an epidural brain bleed so this will not do at all. I ask the nurse to start an IV drip of Clevidipine: a calcium channel blocker that lowers blood pressure and when used as a drip provides better control manipulating the pressure.
While the nurses settle the patient in, I start setting up for an arterial line. The arterial line provides beat-to-beat measurements of the blood pressure (helpful when manipulating blood pressure with drips). I wheel in the ultrasound machine and grab an arrow kit, scissors and a suture needle.
I like to be comfortable while placing lines, so I grab a chair and lower the patient’s bed until it’s an appropriate height. I then prep and drape the patient’s arm sterilely. The artery I plan to insert the catheter into is the radial artery. It is a small artery in the forearm and the vessel of choice for blood pressure monitoring.
Once prepped, I place the ultrasound on the patient’s forearm. I visualize the artery sitting less than 1cm below the skin, take aim and insert the needle through the skin and into the artery. Once I note the flash of blood, I thread the wire by moving the black guide handle down to the feed marker. I then carefully slide the white catheter over the wire and into the blood vessel, and quickly hook the catheter up to the pressure tubing. I look up at the monitor to ensure that I can see the arterial wave pattern on the monitor.
Satisfied, I begin to throw away my sharps and clean up. Predictably, the PA system comes to life and I hear a MAJOR TRAUMA alert with an ETA of 5min. I quickly tidy up and head downstairs to the trauma bay. It is not long before the patient arrives wheeled in by the EMTs. We transfer him to the ED bed while the EMTs give report. He was found down unresponsive, downtown. On my primary survey he initially has a GCS of 3 and is not protecting his airway.. he reeks of alcohol and I suspect he has passed out after a night of heavy drinking. If we intubate him he will have to go to the ICU, taking up a valuable bed… I really want to avoid that. I try a strong sternal rub, bend down, lean into his ear and yell, “SIR!!”. A grimace appeared on his face and he begins to regain consciousness. The rest of my exam is uneventful, no other bodily injuries. Due to his altered mental status, my plan for him is to get a CT of his head and neck to rule out any injuries and let him sober up in the ED before discharging him.
As he is being wheeled out of the room, another MAJOR TRAUMA alert comes over the PA system. 2min. Just as the EMTs arrive with the second patient, our guy from before starts projectile vomiting across the hallway 🤦🏿♂️. The EMTs are unfazed as they wheel the next trauma though a stream of vomit into the trauma bay. They give report. GSW with an entry wound in the LUQ of the abdomen and no exit wound. Patient is hard to arouse and very clammy. On primary exam I calculate his GCS to be 5 E2V1M2. We intubate him immediately with a 8’0 endotracheal tube, breath sounds are audible in both lung fields afterwards. He is still clammy and his blood pressure reads 70/30. The sharpshooters descend on him and place 2 16-gauge large bore IVs. We activate the massive transfusion protocol and hang units of packed red blood cells and fresh frozen plasma. I make eye contact with one of the nurses and ask for them to give the patient TXA to help stop the internal bleeding. Despite our interventions and transfusing as fast as we can his blood pressure remains low and his abdomen continues to grow in size, getting more and more distended and tense.
We make the decision to go to the OR.. NOW! We call up to the operating room and tell them we are coming up for an exploratory laparotomy. It’s a race against time and as we scrub in and get sterile, the surgical staff help get the patient prepped and draped for incision. We perform a quick time-out and make an incision. The moment we enter the abdomen, a fountain of blood erupts from the belly followed by edematous bowels! Its impossible to tell where or what the source is and we quickly pack all four quadrants of the belly. We pause for a minute and collectively catch our breath. Then we commence removing the packs. We start in the RUQ. Nothing. The liver looks healthy and there is no evidence of a bile leak. Next is the LUQ where the entry site is. The stomach looks healthy, however there are several loops of small bowel that have been shredded. Still no source of bleeding. LLQ is next. Nothing of significance. We get to the RLQ and prepare for a gush of blood upon removal of the packing. We are not disappointed. However, the blood fills the abdomen faster than we can identify the vessel or vessels responsible for the hemorrhaging. We re-pack the RLQ.
Meanwhile, on the other side of the curtain, anesthesia is frantically trying to keep up with the blood loss: hanging bags and bags of blood product. TAKE 2. We remove the packing and place pool suckers to evacuate the active hemorrhage from our field of view. We identify the culprit: the right external iliac artery. The vessel is shredded and looks beyond repair. To stop the bleeding, we have to get proximal and distal control of the blood vessel. We split into two teams. I focus my attention on the right groin and make an oblique incision to find the common femoral artery and gain distal control of the vessel. By this time our vascular surgery colleagues have joined us in the OR. We devise a plan to bypass the damaged artery with the great saphenous vein found in the medial aspect of the thigh. By placing a vessel loop around the common femoral artery distally and proximally at the take off of the external iliac, we are able to tie off the vessel and stop the bleeding for the repair.
At the end of the case the repair looks good and the bleeding has stopped. Because of all of the transfusions the patient received in the ED and during the case, he will have to stay on the breathing machine. In addition, the patient’s blood pH is extremely acidotic. We wheel him to the ICU where the true uphill battle to save his life begins..
Dr. Tomi Obafemi is a resident physician in cardiothoracic surgery at Stanford University. He was born in Lagos Nigeria, moved to Chicago, then New Zealand. He returned to the U.S. for college, then attended medical school at The University of Texas Medical Branch.
Check out his blog here: Obafemi-experience.blogspot.com