Big Trouble

My first weekend call was going by smoothly. My resident and I even had time for reasonably thorough rounding. With 40-50 patients, one resident, one attending, and only a few minutes per patient, rounding still takes over 3 hours. We rounded until almost noon on Sunday and took a break for lunch. Then, we came back for a couple of minor afternoon procedures. The town must have gotten the message that we were in the operating room, because the activity picked up. And, as usual around here, there was no lack of variety.

Orthopedics

First, a young man came in after being in a motorcycle accident. Motorcycle crashes are a frequent source of trauma around here. His upper arm was severely lacerated to the point that he couldn't move his hand or fingers and a tourniquet had been applied at an outside clinic. The forearm was clearly beyond salvaging and I recommended amputation. At first the patient adamantly refused. Customarily, any decision for limb amputation has to be discussed and agreed upon by the patient's family before the operation. Sometimes it can take days to make a decision which may result in infection and the loss of more limb (or life). Thankfully, after several family members were shown that his hand was no longer functional, they  quickly came to an agreement to proceed with amputation.

Trauma

While we were doing the amputation, we heard from the ER that a boy had come in with a stab wound. He had a 1cm laceration to his right flank. He had been stabbed about four hours before arriving at the hospital and had a normal pulse and blood pressure. But, his right lower abdomen was tender. His Hct was a bit low (although a Hct can be hard to interpret here as it is not uncommon here to have blood levels that are low just from malaria or chronic disease).

Thinking he most likely had a bowel injury, we took him to the OR to explore his abdomen...and found blood. A lot of blood in the belly...and a large, dark retroperitoneal hematoma behind the right colon going up to the liver and down into the pelvis.

I used to spend time on call as a trauma resident reading a little trauma book called Top Knife to prepare for any worst-case trauma scenario that came through the door. That book described a few select trauma scenarios as "BIG TROUBLE." A large, dark retroperitoneal hematoma qualifies a BIG TROUBLE. Those were cases I looked forward to tackling in the OR during residency. It was exciting to help an experienced trauma surgeon tackle complicated traumatic injuries.

Its a very different feeling to stand in the operating room with an intern staring at BIG TROUBLE without a trauma attending standing across the table. But, there we were, the intern and I, in the OR, staring at BIG TROUBLE.  So, I called for help while quickly packing to get control of the bleeding. Thankfully, I have great surgical partners who willingly come in to help (even on their days off). While waiting for back-up, I fixed a tiny small bowel injury from the tip of the knife and gave some blood.

The ending to the story is a bit anti-climactic (which, really, is a good thing).  After preparing to tackle a major IVC injury, we explored the abdomen again. The bleeding from the retroperitoneal laceration had stopped. The hematoma was stable so we decided that the safest thing was to leave the hematoma alone. And I'm glad we did. As Top Knife says "this is a unique situation in trauma surgery where you may deliberately flip a controlled situation into an uncontrolled calamity."

The boy recovered quickly and was up and walking and eating within a few days.


Pediatrics

As we were closing the boys abdomen and my heart rate had returned to normal, a baby with an incarcerated inguinal hernia came in. We fixed it...and went home. First weekend call...check.