Weekends are hard to predict around here.
I’m on trauma call for the hospital, so I need to stay close to home and close to my phone. But beyond that, life goes on as usual. Saturdays and Sunday are great family days, we try to sleep in, make coffee, and I’m on breakfast duty.
The kids get “screen time”: Finding Nemo for Jane, Minecraft or reading books for Michael. It’s the cold and rainy season, so a roaring fire and fuzzy PJ’s are mandatory.
It’s great not having to rush off somewhere or have anything to do. I make my way down to the hospital storage room to organize some donated equipment and get rid of a huge pile of useless junk.
The kids have friends within walking distance, RVA has high school rugby games to go watch, and dinner plans with great friends round out a perfect Saturday. A peaceful start to the weekend.
Sunday is another story. My phone jars me out of a sound sleep, the screen tells me it is the ortho resident calling. I don’t really know what time it is, I just know it’s dark.
“28 year old guy on a piki (motorcycle), hit by a bus about 4 o’clock this morning. Pelvic fracture, bad open floating knee. Has had 4 units of blood, his BP is 100/50, and we’re on our way to theatre. His Hemoglobin level is 5 after the third unit of blood” To translate, this man is bleeding to death, he has already lost at least two thirds of his blood volume. Only healthy young people survive such blood loss, but they can die very quickly once their ability to compensate is overwhelmed.
Okay, I’m awake now. I volley back some questions: is the pelvic fracture stabilized with a binder, does he have two IV’s flowing wide open, is more blood available, is he alert, can you feel a pulse in his leg, have antibiotics been started, has he gotten a tetanus shot, any chest or abdominal trauma, has his c-spine been cleared?
Yes, yes, yes, yes….The systems have worked, protocols have been followed, and this young man is going to have the best chance he can at survival and keeping his leg. I’d like to repeat that sentence 10 more times, because it is amazing. At this little hospital clinging to a muddy hillside in rural Kenya, this patient is receiving world class trauma care. This is all down to the excellent work of the junior residents who met this man in the emergency department. We don’t have a sophisticated lab to know his acid-base balance, we don’t have invasive monitoring to know his exact fluid resuscitation status, but within our abilities, every possible thing has been done, and is being done, to save this man’s life and limb. In medical parlance, we move into “damage control” surgery.
The goal of damage control surgery is to stabilize the patient, quickly clean wounds, stop bleeding, and get him into the expert hands of the intensive care unit doctors. Damage control does not involve meticulous repair of wounds or fractures, just quickly trying to move him out of a life-threatening situation.
I gulp down a cup of instant coffee to clear my head and walk into the pink sky of the breaking dawn and down to the operating room. The patient is just being wheeled into theatre, and I introduce myself and talk to him, in as reassuring tones as I can, about his injuries. I’ve had more than one patient here with these same injuries never wake up from surgery, but he doesn’t need to know that right now. “Your blood pressure has stabilized, things are looking good, we’re going to clean up your wounds and begin stabilizing your broken bones.”
With that, the nurse anesthetist gets him off to sleep while we stabilize his neck. He hasn’t yet gotten an Xray of his neck, and has no pain there, but could easily have a broken neck and not know it. The pelvic and limb fractures are painful enough to mask the pain of other injuries, so we always assume the spine is broken until proven otherwise.
The leg looks bad. The thigh bone (femur) is broken and sticking out the front. A large segment of the tibia bone is missing beneath the knee, and there is a clot of blood behind the knee. Through my gloves, I can feel a pulse behind his knee, so we know the main artery to his leg is intact. With a doppler probe, we can see that he has good blood supply to his foot. So the leg is probably salvageable. But that clot behind the knee looks ominous. We leave it alone, to be looked at more carefully a bit later. Before he went to sleep, we had tested his ability to move and feel his toes, and this was normal. Some reasons for optimism. But the clot worries me.
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We wash debris, paint chips, gravel, sand, and pieces of his trousers out of the wounds. The fractured ends of the bones are tattooed blue from the paint on the bumper of the bus. We meticulously clean everything, excising dead tissue, until the wounds look clean. The residents and I install an external fixator, a stabilizing device which uses pins inserted into the bone to attach to a carbon graphite frame. This can be applied in a matter of minutes, from his upper thigh to just above the ankle, to provide some stability to the leg.
The patient is getting cold. Hypothermia, or below normal body temperature, is a common and ominous sign in severe trauma. We get hot water bottles and blankets to cover every square inch of the patient that is not being operated on. A cold patient can have severe metabolic disruption, including losing the ability to clot his blood. This can be irreversible and fatal in a severely injured patient. We turn the room temperature up to 86 degrees Fahrenheit. While garbed in hats, masks, gowns, and lead vests, this becomes very uncomfortable, but is standard trauma protocol.
The wounds are clean, the fractures stabilized, and now it is time to go back and look at that clot. I carefully place retractors to hold the surrounding tissues out of the way, and gently remove the clotted blood. Before the case started, I had insisted that everyone in the room was wearing eye protection. And this was why. As I removed the clot, bright red blood began spraying out of the wound. We had found the reason his hemoglobin blood levels were so low. As the bumper of the bus hit his leg, one of the bone fragments had torn a hole in an artery in the back of his leg. Gentle fingertip pressure stopped the bleeding, and we called for the talented general surgeon, Dr. Jack Baraza.
Jack was waiting in the wings, and quickly arrived to calmly explore the vascular injury. There are three vessels which supply blood to the lower leg, and two were still intact. So the repair was a simple matter of isolating and tying sutures around the offending blood vessel. We rechecked the blood supply to the foot, and after a few tense moments, were rewarded with pink toes and a visible pulse on the doppler ultrasound screen.
Thick dressings are applied, a plaster splint reinforces the external fixator, some other wounds are quickly sutured, and the patient is ready for transport to the ICU. He has a long and difficult struggle ahead of him. The next 48 hours will show us how much reserve he has left. As he stabilizes, we can begin to plan reconstructive surgeries to fix his pelvic and femur fractures, and restore the bone missing from his leg.
I walk back home to an empty house. Ann and the kids are enjoying Mother’s Day by going on a hike at Crescent Island with some friends, so I have some breakfast and get ready for a nap.