Trauma Surgery: first week

Phew. So trauma surgery. Whew. Yeah. So its better than general surgery but its not.....surgical. Its a crazy mix of IM & ER.   ER part comes from dealing with the traumas. But when we get a trauma but we don't just stop there. Trauma service manages patients for days until they get discharged from the hospital. We even have trauma clinic where those patients follow up even after leaving the hospital.

So that said, traumas are surprisingly simple, if you can get over the frantic, bloody, crowded, chaotic atmosphere. Because the truth is there are only so many things that can kill you in the next 5 minutes. And trauma's job is to make sure those things are identified as quickly as possible.  Broken bones, lacerations, bleeding, pain are not even on the radar for trauma. The one and only job is to make sure you stay alive for the next 5 minutes even if it means hurting the patient (aka no pain meds, yanking on broken bones, always checking rectal tone).  Standard procedure involves cutting off your clothes, do a trauma series (aka CT head, neck,chest, abdomen, pelvis) and stat chest xrays, 50 very personal questions, exams of every part of your body, including rectal exams on everyone, checking pulses, listeinng to heart and lung sounds, and more in under 60 seconds. To be a real trauma center, we must have all these things done (by multiple people) in literally under 75 seconds. It def helps to increase the frantic atmosphere. It is hard to not constantly feel like you are in the way. It also makes it hard to help if you don't know what to do or exactly how to do it, while staying out of everyone else's way.

Despite the word 'trauma', the service is disappointingly devoid of blood and guts. We've only really had about 1 trauma per day. It seems to be primarily consults when patients turn critical or other services won't admit.  Its frustrating because oftentimes, we are just babysitting a patient for neurosurgery because they do not admit their own patients. To top it off, trauma surgeons must stay licensed in general surgery which requires 'typical' procedures like a PEG tube, placing a trach, taking out an appendix, etc.  So for 1 week of each month we take 'surgery call' so whenever surgery needs to be consulted, they call trauma instead.

When there are traumas they are classified in 3 levels of trauma in order: consults, priority, alert. Alerts are rare, but if they come, you run. So here are some patients, to better explain this.

CONSULTS

An older gentleman shows up at the ER (war veteran- predictable right?) because of a fall 2 days ago. He thought it would be okay, but despite extreme bruising on his shoulder(craziest bruise i've seen yet), he let it go a few more days.  And soon it was 2 weeks later and he admits to not moving his right arm since the fall. And he is profusely uncomfortable that he had to come in at all. He is apologizing and promising he's not a wuss but he is extremely tender and said something might be "grinding around in there." And then of course we get this xray back. Yeah. That's CRAZY broken.

PRIORITY

This was a 21y.o. male who was in a MVC (motor vehicle collision) he was a backseat passenger where he was ejected. The car rolled over him. The driver, his girlfriend, was fine because she was wearing her seatbelt. He arrived at the hospital awake but on a backboard and cervical collar. There was blood in lots of places from a scalp wound as far as we could tell. He had a tibial fracture and back pain. We put in a foley catheter (for urine) and he starts getting upset because he can't feel it.  Then we roll him over (per protocol) and do a rectal exam, which reveals gross blood and no rectal tone. He starts screaming and finally we figure out he can't feel it. We do xray and CTs and find something strange: a completely isolated, shattered L1 vertebral fracture.  If you look up at this close up I provided you can see some pieces that are pushing on the cord. This is bad. So we try to calm him down because the cord itself isn't broken, its just being pushed on.  I rounded on him this week, because obviously this is a trauma case we admitted for.  Its important that I mention that he can move his legs and walk fine, despite his broken ankle.

So I walk in his room to find out how he's feeling and he's laying in his hospital bed sleeping (cuz its 5am) and there is a woman in his bed who is spooning him and rubbing his chest. I am a little shocked, is this his girlfriend?  Didn't he just ask me for my number in the trauma bay? I go ahead and waken him up and do the exam and whatnot and discover this is his MOTHER.  Weird. Then i get in trouble at rounds because i didn't think to ask him about his genital sensation and his function. So i return over the next several hours and have to ask him in front of oh, maybe 6 people who are his friends and family if he's had sensations or erections. He says he doesn't know, would i look for him....  and now i don't know if he's flirting or actually scared to look. Um, way to go bioethics for not preparing me for this dilemma. anyhow, i choose not to look obviously.  But i get chewed out during rounds for not being able to answer all the attendings questions, but half of the residents are laughing.  And I'm seriously confused about what i'm actually expected to do medically.  I mean I've seen plenty of penises, but rarely in front of family members and rarely do i want the patient to stimulate an erection.  Can't he go into the bathroom or something?  Isn't there a morning wood phenomena?  Anyhow, I actually haven't asked him yet. And just chose to be yelled at by the docs this morning instead.  He did have surgery to fix his back and they discovered an anal tear which we fixed. He still wasn't having sensation (which was assessed by me waiting for several awkward moments while he played with himself in front of his mom and it wasn't under the sheets). However, we did a void trial (took out the foley to see if he could pee on his own) which he couldn't.  So we also did another rectal exam, in which he couldn't feel still but he doesn't have any more blood.  So its been several days and still no changes (this isn't looking good) so we had to consult urology and teach him to catheter himself.  So I'll update this post with edits on his progress, but the real possibility we talked about at rounds is he might have to get a colostomy bag and may never be able to use his rectum or penis again, even tho he can walk.

Now this whole situation brought up another weird medical joke/issue that is for real and people did studies on it. Throckmorton's sign. Its a real thing, tho I question how they got research grants for this. Google image it. I dare you.

ALERT

And sorry, but with alerts things were so crazy... i didn't get many pictures. Its hard when you're running about. However, we had two cases this week.

The first was a 5 month old that was lifeflighted in from a smaller hospital. Apparently the story was several days ago he was seen for nausea and vomiting, he was given antibiotics but he returned that morning for seizures.  They couldn't figure it out so they did scans. We didn't know anything but this story when we got the kid.  He was awake and looking at everyone, he moved all four of extremities, but something about the kid was off.  For example, we needed and IV and stuck him at least 8 times including on his head (for scalp veins, this is common practice for babies because they are big vessels for emergencies)... but this kid didn't cry. He just whined the first time and only once. Then he just watched us.  Something was definitely off.  We got a CT scan and saw a huge brain bleed.  Apparently it came out slowly that this was my very first case of shaken baby. The saddest part of this story is that he did not get better.  He went directly to the pediatric surgeon whom i hunted down and he said he expects the kid to be mentally retarded. He will probably never be potty trained, will only learn to walk if he's lucky and may not be able to speak.  Likely he will be put in some facility to stare are the walls and lights in permanent nursing home for the rest of his life.  I looked at the parents when we told them this and I don't think they realized until that moment. Shaking your baby, even in a moment of anger, is something you can't ever take back. Not only will the kid be taken from you but they will cease to be the kid that you could have had. After they were told, the entire staff treated the parents worse than i've seen anybody treated, they were outright ostracized, glared at, and one of the surgeons even flipped them off. (professional i know).  It was strange because it was very emotional for everyone on staff.

The other case I have to talk about quick. A lady slammed on her breaks because she wanted to avoid running over an animal on the highway. The semitruck behind her slammed into her car, shoving her into oncoming traffic where another semitruck hit her head on.  We referred to this as a semi-sandwhich. Surprisingly, she was awake and lived. Though her injuries were extensive and had quite alot of blood loss.  It took 3 medical students to suture her wounds closed and I (by myself) threw about 32 sutures.  Plus we had 1 resident sewing up her face. The weird social situation that surrounded this lady was her daughter who was in the waiting room. I went to get her after my sutures and she was more nervous than usual. I guess she was adopted as a child and had only met her biological mother (the one we just sewed up) about 2 months ago. She had no idea how to feel or what to say. It was very awkward.  This picture is of an acetabular fracture (the bony cup that holds the femur head in your hip), its on the patient's left-- and its kinda tricky to see. The biggest thing that we worry about in trauma's with pelvic fracture is bleeding. Usually if you bleed from a vessel, it will bleed until the pressure around the vessel is more than the pressure in the vessel which stops the bleeding. In pelvic fractures the bone structure is broken, allowing the soft tissue to slack. There is a lot of space in the pelvis. So much so that it could hold half your body's blood supply-- more than enough to cause death by bleeding out. However,  if your pelvis in intact then the pressure will eventually overcome the bleeding, if it is broken, you can bleed out fast, with no outward signs.

So anyway I have to sleep or I might die....