By Conrad Murphy
Somewhere between the second and third year of medical school, you start to grow tired of the phrase “You can’t just know the information — you have to apply it.” They keep telling us that, but they don’t exactly tell you how to do that. Medical school is a game of memorization in large part. How many tidbits of information can you squeeze in your brain? Not only that, but can you dig it back out after months of putting it in?
“Mr. Murphy, what are the hard signs of an arterial bleed?” Well, let me go excavating the deepest caverns of my mind where my mother-in-law’s birthday resides along with the name of that Scandinavian group that had a killer song come out during high school (sorry mom-in-law, I am trying my best!). Sometimes I was able to dig out the information in time to answer the attending, sometimes I couldn’t dig it out, and sometimes I just never put it in.
A popular analogy compared the volume of medical school knowledge to drinking out of a fire hydrant. My favorite, however, was imagining that you had to eat 12 pancakes every day as a student. If you only ate eight of your pancakes today, tomorrow you’d have 16. One of the many tools that medical students have at their disposal to eat their fictional flapjacks is a computer program. It’s essentially just a fancy system of flashcards. It gives you a prompt and you fill in the blank by thinking of the answer (hopefully we all know what flash cards are). A pleasant day of studying for me is going to Round Mountain Coffee, grabbing an aromatic pour-over from some incredible Rwandan coffee beans, and dredging through a few hundred flashcards that morning. Usually, I have headphones listening to some music. Swedish House Mafia, haven’t heard them in a while.
How does cardiac output change in hypovolemic shock?
Decreased
Only 387 more cards to go. A few months earlier, I was on a trauma surgery rotation. I enjoyed the pace of it while slowly embarrassed my way around being in the emergency department. Seeing how the interprofessional team operated when traumas came through the door was the most rewarding part. I signed up to receive the trauma pages on my phone, so I knew when to head down to the trauma bay no matter where I was in the hospital. The first one came through on that particular day:
Level 1 MOI: mcc trauma code
It was a level 1 trauma –, the mechanism of injury was a motorcycle crash. Typically, they included heart rate, blood pressure, and the Glasgow Coma Scale number. They also usually gave the estimated time for arrival, but as we soon found out, there wasn’t time for any of that to be included in this case. I took my spot at the whiteboard where I was the one writing down all the physical exam findings, given timekeeping medications, and completed procedures. Once the cart rolled through the main doors of the department, I could only see one of the nurses turn to give us a grim look. Our patient came through the doors, and I immediately noticed the LUCAS device automatically giving compressions onto his chest. It was a violent machine. The thrusts shook the rest of our patient’s body, sacrificing all manner of gentleness for efficiency.
All at once, the team coordinated decisive actions and employed closed loop communication to establish intravenous access, place an airway for ventilation, and continue resuscitation to bring him back to a stable rhythm. At some point the device was removed and although he was grossly unresponsive, a flicker of cardiac activity came across on the EKG monitor. The decision was made to pursue an emergency thoracotomy in the ED to attempt cardiac massage. This was an effort to provide direct compression with hands directly to heart. The resident made an incision on the left chest wall, applied rib spacers, and mobilized the heart in what seemed like five seconds. Through the organized chaos I saw her hands rhythmically squeezing the ventricles with her palms, one hand above and below. After some time, the trauma team leader called a time of death. We debriefed before cleaning up the room, taking used needles into safe containers, picking up wrappers from all the equipment that was used, and cleaning the floor as best we could. Most importantly, we sought to retain the dignity of our patient for his family that was waiting a couple doors down for news. I wiped down the whiteboard to get ready for the next trauma to come through.
I thought about that trauma page for a while. I knew that thoracotomy procedures in the emergency department were rare for students to witness. Although I was extremely sad for the patient and the family, I felt somewhat privileged to see one. I had only heard about the procedure in textbooks and watched healthcare documentaries that mentioned them. My mind tracked back to the resident’s hands holding the heart, beating for it.
What is the next step in management for a patient with penetrating abdominal trauma without peritonitis, evisceration, or hemodynamic instability?
FAST scan → if negative → CT
A few days later I had my only trauma call shift for my surgery rotation. Every student was required to do 24 hours of trauma call, either all at once, or split into two days. Fortunately, I had already been on a trauma rotation for a couple weeks and knew what to expect. I showed up for my regular day on the trauma service and stayed behind afterward to carry my shift through the night. I had almost no trauma pages come through for the first several hours of that evening. I was studying and eating pizza in the team room by myself for a while.
The first page came through sometime around 11 p.m. It was a transfer from another hospital unable to appropriately care for the patient due to limited resources. The trauma was some sort of accident with a piece of yard work equipment. It was a straightforward assessment — not much to write on the whiteboard since our patient had already been sedated throughout travel and she was stable before she even left the previous hospital. Our attending physician already spoke with the patient’s previous surgeon about plans for a surgical repair the next morning. Our job tonight was to make sure they were stable when they arrived and start making progress on the repair if we could. I didn’t realize it at the time, but another page had come through while we were already in the emergency department.
Level 1 MOI: GSW R flank, MTP activated HR/SBP/GCS:100/80/14 ETA: 20 min.
It was a level 1 trauma. The mechanism of injury was a gunshot wound to the right side of the lower back. There was a significant concern for blood loss, so they activated Mass Transfusion Protocol, a method used to preserve and replace blood loss to patients quickly. The patient’s heart rate was at the upper limit of normal, not uncommon for trauma patients. The blood pressure was significantly lower than the normal range, a sign that somewhere the patient may not have the blood volume to adequately support oxygen delivery to his tissues. Finally, the patient was supposed to arrive in 20 minutes, but those minutes had come and gone while I was with the first patient. My attending had already left after our patient was stable and he went to meet the ambulance when it arrived.
I walked right over to the next trauma bay and heard the usual callouts and scattered noise from the physical exam and various procedures. I saw the patient on the table — a man writhing in pain and discomfort. His GCS score was 14, a good number, meaning that he was responding appropriately to the paramedics during the ride to the hospital. The nurses in the trauma bay were asking him his name and about his life to keep him engaged and to assess his mental status.
What is the management for a penetrating wound below the T4 intercostal space in hemodynamically unstable patients?
Exploratory Laparotomy
At some point it was decided that they needed to take back our patient for emergency surgery to try and stop some sort of bleed that the bullet may have caused when it entered the patient’s back. In a matter of a few minutes, he was intubated and sedated; he moved to the elevators that would bring him to the operating room. I left the trauma bay to join our attending and resident in the case. I hadn’t yet seen an exploratory laparotomy and needed to see one prior to finishing my clerkship. I didn’t quite know my role in emergency surgery as a medical student. I stood in the OR while the attending, the resident, the anesthesiologists, and the other operating room staff prepared our patient for surgery.
“Conrad, scrub in, we’re going to need your help.” My attending had started painting our patient with an antiseptic solution. I went outside the room and scrubbed in, thankful to have the opportunity to help and see where the case was going to go. I walked back in and gowned up with the help of the nurses and surgical technologists there. The room felt very much alive, everyone was alert, active, and ready to go despite the hour going past midnight. As the gloves slipped across my hands, the surgeon made an incision from the bottom of the patient’s sternum all the way to several inches below the navel.
I was helping to retract the abdominal wall while the attending and resident started the laparotomy procedure, packing all four quadrants of the peritoneal cavity to stop any bleeding and to look for any sources. To me, it was a very important and personal thing to see our attending carefully searching every surface of our patient’s abdomen to look for any lacerations or abnormalities. Immediately he noticed some portions of the patient’s bowel that needed a resection. He asked for a unique sort of stapler, one that I hadn’t seen before. He quickly moved a slide across two surfaces of bowel, taking out the damaged portion while sealing off the healthy ones. We’d come back later to anastomose the portions, since it wasn’t the most pressing issue at the moment. As he moved to the left lower quadrant of the abdomen, I heard him say, “Here we go.” He pulled out what looked like a metallic piece of popcorn, the warped bullet that had somehow found its way to the patient’s lower left side coming from the right side of his back when it entered.
He dropped the fragment into a container and continued to work. We kept looking for a source of his bleeding, scouring every surface. We mobilized the kidneys and saw that his right kidney had been lacerated by the gunshot, but there was no active bleeding coming from the site.
“Guys, his pressure is in the tank.” The anesthesiologist shouted as he leaned over the drape at the head of the table. We all looked up to the large monitor and saw the change. He was previously around 80mmHg of his systolic pressure while being transfused with blood, but now was fluctuating between 30-40. We turned back to the patient and worked faster, knowing that we needed to find the source of bleeding fast. The anesthesiologists continued to transfuse blood as fast as possible and the bags of blood products stacked up on the table beside them, ready to be emptied.
The attending went back to the patient’s right upper quadrant and after dissecting further, a pool of old blood began to rise and flood his abdomen. We suctioned as much as possible to help him see where it was coming from. He found the source, but the blood resurfaced so quickly that he only had milliseconds at a time to visualize the patient’s anatomy. We switched to a stronger suction device and pulled out most of the fluid.
“Sponge sticks, now!” The surgical technologist handed him two large forceps with packed gauze on the end of them and he pressed them down deep, looking to stop blood flowing from both the proximal and distal end of a possibly transected vessel.
“It’s probably the IVC.” The inferior vena cava was the largest vessel that brought blood back from the lower extremities into the heart. A transection of that vessel would certainly cause the immediate blood loss we were seeing. If this was directly caused by the bullet, I couldn’t grasp why we were just now seeing hemodynamic collapse. At that point, it didn’t matter why.
Unfortunately, we had a very difficult time keeping up. It felt like every drop of blood being transfused was just being lost through the suction. Our patient’s heart couldn’t survive with such low volume. The anesthesiologists told us that his pressure was so low that his heart was beating erratically and skipping beats altogether.
We started chest compressions to help push blood to our patient’s brain, beating for the heart through his chest wall. I pressed deep with each compression, trying to keep the pace that I was taught. We had intermittent moments where the heart found its rhythm again. We had moments where it seemed like the bleeding was controlled. But again and again, it came back.
“We’re doing a thoracotomy.” The attending physician showed me where to press on the sponge sticks to keep the IVC occluded so he could help the resident to mobilize the heart from the thoracic cavity. “Do not move, whatsoever!” He said as he left my side of the table and walked around. I pressed hard with intention, looking for any kind of loss. Our suction was still taking up some blood, but it wasn’t as substantial as when we first found the source.
The resident made an incision on the left side of the patient’s ribcage, just like I’d seen another do in the emergency department a couple weeks prior. They took out separators to move the ribs so they could mobilize the heart for cardiac massage. After a couple short minutes, I saw the resident wrap her hands around our patient’s heart and rhythmically squeeze out the blood after it began to fill. We continued like this for a minute to monitor his circulation. I could feel my entire back and brow filled with sweat from pressing hard and leaning under the lights for so long. After about 30 seconds, we started to notice that the bleeding started welling not from the right side as much where I was holding the sponge sticks, but from the left. Another red flood began to fill the patient’s abdomen.
“Conrad, I need you to take the heart now, let me take those.” He grabbed the sponge sticks from my hand. He needed the resident’s help to control the other side of bleeding and to stop it where we could. I quickly walked to the other side of the table and placed my hands under the resident’s while she gently slipped hers out. The heartbeat was strong in my hands — a perfect push and pull of cardiac muscle. I felt the rush of fluid come and go out of the chambers. “Now you see it’s beating well, you don’t need to squeeze much if you see it beating well, but if it fades, you need to squeeze the blood from the ventricles up to the vessels.” They continued to work away while I watched the heart in my hands beat, occasionally giving support with my palms.
In our medicine courses, our instructors emphasized “treating the whole patient.” Don’t just treat the lab value, the abnormality, or even the disease. Treat the patient. In those moments with our patient’s heart between my palms, that instruction didn’t apply. It felt like the heart was the patient. It was the only thing that I could tangibly see alive. I was struck by how well it was working despite the complications we’d encountered so far. By this time, another trauma surgeon had rushed in, just finishing up another trauma evaluation in the emergency department below. She filed in with us, looking to help control the bleeding. It was just too deep. One step forward, two steps back.
We weren’t keeping up. I felt the walls of the heart start to slowly give way beneath my hands and I found myself squeezing for almost every beat. For those unfelt beats, they were erratic, unorganized, panicked. Before long, I could tell that my hands were providing all of the effort. Several anesthesiologists on the other side of the drape were looking down at my hands, looking for any signs of activity aside from my own.
“Everyone, please stop, stop transfusing guys.” There was no more progress to be made. Our patient passed. The room was silent aside from a couple sounds here and there from the monitor. We shared a couple seconds of silence together and our attending debriefed the team. We each went around the room sharing any thoughts. One thought that struck me came from a nurse that said he was able to tell her his name. It was true that it felt different to lose a patient when they came in and able to speak. A couple weeks earlier, the patient who came in was completely unresponsive. We were inclined to expect a poor outcome. The situations were each very dire, this one more insidious.
“If this happened to me, I would want each one of you here,” another nurse said. I wholeheartedly agreed. Heroic actions aren’t always met with similar results. The attending surgeon nodded with his eyes at the ground as each person spoke. He thanked everyone in the room afterwards and left to go speak with our patient’s family.
The SPIKES protocol can be used to deliver bad news:
S- Setting
P- Perception
I- Invitation
K- Knowledge
E- Emotions
S- Summary
The rest of the night passed as a blur. As the sun rose over the hospital buildings, I drove home, the adrenaline from the night gone, the images of that case creeping back to my mind. I remember losing tears on the way home, some from exhaustion, most from sadness. When I arrived home, I fell asleep after a while. I found it somewhat cruel that I was finishing my surgery rotation next week and would be moving on to something else while the same attending and the resident stayed on call throughout the month.
Going through my flashcards, I came back to myself in the coffee shop. I didn’t have any that gave insight on that case — no cards on how to handle the drive home, fall asleep easier, or get up and go the next day. From that point I started to see the hospital differently, my kids differently, even myself. What is there to do in those circumstances? At least there’s one thing: We can do our best to remember the suffering we see and the bravery of those doing everything they can to help.
Conrad Murphy is a third year medical student at UAMS. He lives with his wife and two daughters in Conway, Arkansas.