Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER (14 page)

“Let's roll him over,” is all you say.

Donna and the paramedic help you roll the patient. There are two exit wounds in the back. They are angled off toward the left side of the chest wall and downward. One of them is angled far enough that it probably went into the abdominal cavity. If these are exit wounds, then whoever shot the kid was standing to the right with his shooting arm angled down.

Through-and-through chest wounds, vital signs in the field but lost by the time the patient arrived at the ER.

Precious seconds are ticking by while you stand there trying to think of a good reason not to open this kid's chest.

Open a chest. Is there anything you can do other than to open this kid's chest?

No, it's his only chance.

There is no time to get a surgeon in here. So you, the ER doctor, must open the chest wall to expose the heart. If there is a hole in the heart, you sew it closed; if the heart is not beating hard enough, you try open heart massage, squeezing the heart manually; if there is uncontrolled bleeding in the lower half of the body, you cross-clamp the aorta. All you are trying to do is buy enough time to get the surgeon here and the patient to the OR.

The prime candidate for a thoracotomy, the technical term for cracking a chest, is someone with penetrating trauma to the chest who had vital signs at some point in the field or in the ER. Just like this kid.

Of course, you will have to open his chest.

“Get the thoracotomy tray,” you tell Donna. “Get me some gloves. Anyone get through to the thoracic surgeon?”

“You know,” Donna mutters, ignoring what you say, “these
stupid
kids go out and get shot and expect
us
to save their lives…”

There's no time to make more than a pretense of sterility, but you do make two concessions to the era of AIDS: you put on a pair of clear goggles, oversized to fit over your glasses. Then you double-glove.

Above you, J. T. is getting the fluid warmer set up and the blood transfusions started. Bill, the tech, has taken over doing CPR, such as it is. His hands keep slipping off the chest because of the blood.

Two bags of normal saline are already running wide open via snaky IV tubes into veins in the patient's arms.

Donna finds the tray and brings it over. It's wrapped in a gray shroud-colored drape and enclosed in plastic wrap to keep it sterile.

You open the kit. There is a haphazard array of clamps and retractors, needle drivers and towel clips, most of which you won't need. As you paw through the instruments, you remember some of the eponyms; the names are a parade of the great physicians of the past: Mayo, Metzenbaum, Fienchetto, DeBakey.

There is only a scalpel handle in the tray. No blades.

Even you, the calmest of doctors, look around impatiently. “Where the hell are the scalpel blades? What the hell are they thinking of? I need a ten-blade over here.”

There's a momentary echo within you, from those TV shows. “I need it
stat
.”

You cast a weather eye up at the monitor. There is still a heart rhythm registering there—the electrical part of the heart is still working. J. T. feels again at the angle of the jaw for a carotid pulse.

“Anything?” you ask.

“Nada.”

Bill is still doing CPR with his hands over the bullet holes. Before you motion him away, you look around, taking a big, deep breath. Beyond you all, out in the hallway, the radiology technician is leaning against his portable x-ray machine, watching all of you with judicious interest.

Someone hands you a 10-blade.

Now the approach. You've drawn this picture a hundred times for the medical students. A sketch of the chest: the nipple, the inframammary fold. Then you trace on your little diagram the imaginary incision site, between the fourth and fifth rib, you explain to the bored medical students.

Now, as you stand there, scalpel in hand, you think back to the first thoracotomy you saw. You were a medical student; it was your first clinical rotation, surgery. The team had been called down to see a man in the ER who had been stabbed in the epigastrium—just under the sternum. He had lost his blood pressure by the time you and the senior surgical resident arrived. The resident called for the thoracotomy tray and tore the chest open in record time. Before you even got your bearings on the anatomy of the procedure, there was the man's heart. You could see it beating, or rather, you could see it intermittantly flopping around like a fish on dry land. You remember now that weird hot-and-cold feeling; and you knew you were going down an instant before you did so. You woke up to a circle of faces and someone poking a finger on your right hand, checking your blood sugar. Ultimately, the man died. They always died. What was the figure you were quoted once? One out of a hundred? That was probably optimistic.

One out of a hundred, you think, as you look down at this kid's chest. There's the chest wall, the inframammary fold, but this time it's not a drawing; it's live flesh, a skinny boy's chest with hairlets sprouting around the nipple. This is it.
Now,
you tell yourself, pointing the scalpel blade down. You trace the start of an arc. Nothing happens; the flesh stays pristine. You try again. Nothing. You pause, thinking,
nightmare!
Then realize you have the scalpel turned upside down.

You try once more and this time the flesh parts. You make your cut from the midpoint of the chest, the sternum, all the way around the chest wall. You go through skin, the epidermis, the dermis, into a layer of subcutaneous tissue, the knife passing through the flesh as if were warm butter. (This is the physical pleasure of a fresh blade.) Small red blood vessels spring open, dotting the yellow fat red.

“Metzenbaum,” you say to Donna. These are scissors, long and curvate. You use these to cut through the rib muscles. To position them you have to push one blade through the muscles of the chest wall, entering the pleural space. As you do that, the lung collapses away from you, deflating and falling back into the chest cavity. With a couple of hefty snips you have your first glimpse into the chest cavity. You can't see anything but blood.

Fienchetto is the next physician's ghost you call upon. He is responsible for the rib spreaders. This is a device with two parallel bars connected to a simple gear. A handle turns the gear, causing the two metal bars to separate.

The metal bars each have a U-shaped edge. You hook the top bar edge under the fourth rib and the bottom bar edge over the fifth rib, and then you start turning the crank. As you do, you hear a cracking sound, like kindling catching fire—that's the sound of rib bones breaking.

You have to break four or five ribs before you can see enough to do any good. This was where those guys on TV were when they peered timidly and discreetly into the human chest. (Yes, yes, I see the aorta, one of them had said woodenly.) The truth is, you can't see anything. Nothing is textbook, because all those textbook drawings were based on someone who was definitively dead, not half dead and still bleeding like this patient. Right now, all you can see is blood pouring from the hole you have made in the chest wall.

But wait. You give the bleeding a moment. After the initial tidal wave of blood, it subsides. You mop around with some gauze sponges. After a moment, with your face down inches from the chest wall, after more swabbing, you see a liverish, collapsed lung and beside it, something else quivering in the dark.

There it is, the naked heart.

The trouble is that it doesn't look as it should. This kid's heart should be about the size and shape of a big man's fist. Instead what you see is something much larger, something that looks like a small head of cabbage.

“Sponges,” you say aloud. “Is anybody getting blood started on this kid?”

“Keep your shirt on,” Donna says.

“Well, someone hand me some more sponges.”

They are stuffed into your outstretched hand. You mop around some more, surprised that the blood you've blotted doesn't reac-cumulate all that fast. There it is: a quivering purple ball, not looking even remotely like a heart. But it is the heart, and as you see it, you realize what has happened; you see why this patient has no blood pressure.

The heart is a muscle, or rather a complex set of muscles, surrounded by a tough, two-layered membrane called the pericardium. At least one of the bullets has gone through the pericardium into, and probably through, the heart. Blood from the hole in the heart has leaked out now into the pericardial lining, turning it into a bulging sack.

With each beat of the heart more blood is pumped into the sac. Because the sac is not elastic (it has the feel and resistance of a plastic bag) the heart must occupy a smaller and smaller volume. As the blood collects in the sac, the heart reaches a point where there is no room to receive blood. That's where it is right now.

“We've got pericardial tamponade here, folks,” you announce.

You look up for the first time in several minutes. There are two units of type O-negative blood—blood from “universal donors,” along with several bags of normal saline. You know that half the blood pumped into this kid is going straight to the pericardial sac. Until you drain the pericardium, that is exactly where the blood will stay.

“The thoracic guy,” you say. “I hate to bring this up again, but if we don't have a surgeon, then I may as well quit now.”

“We've got him on his car phone,” Donna tells you. “He's en route.”

So you've got pericardial tamponade. You will have to open up the pericardial sac and drain the blood that has collected there. Then you will have to find the hole in the heart and in some way try to stop the bleeding. That is this boy's only chance.

But there is the problem of the phrenic nerve. The phrenic nerve powers the diaphragm. If it gets cut, the patient never takes a breath using his left lung again. The nerve descends from the brain stem along a tortuous path that you hope never to be asked to memorize again. The important part for you is that it runs along the left side of the pericardium, right about where you have to put the incision to drain the blood. Some supreme medical lan-put guru has designated this hole as a “pericardial window,” a window you can use to drain out all that blood collected within the pericardium.

But you have to find the phrenic nerve, so you won't accidently transect it, and there's nothing but blood here. You are looking for a narrow ribbon, a yellowish stripe, but all you can see is more blood, more blood. Seconds are ticking by; you can feel each one of them slip past you. Finally you say, “I think that's the nerve,” pointing, although no one else can see and you are not really convinced. It doesn't matter. You have to move.

You make a small, experimental stab at a place just in front of whatever that was you saw running down the pericardium. There's nothing. You snip again and suddenly, there is blood everywhere.

“Whoa,” J. T. says.

Blood splashes against your goggles and all over your jacket. You've unloosened a torrent of blood that quickly fills the chest cavity and overflows onto the floor. It looks as if every ounce of blood that should have been in the kid's body had leaked into the pericardial sac.

“Sponges, for Christ's sake.”

Still the blood keeps coming. You start mopping with what you have, but you can't keep up. All pretense to sterility is gone now. You are up to your coat sleeves in the blood in this boy's chest. The blood has cascaded down onto the floor. There are two inches of blood where you are standing. Your shoes are soaked with it.

You get your fingers down into the pericardium and start removing blood clots, which you sop up using the sponges Donna keeps throwing at you. The bullet holes had caused blood to leak from the heart to the pericardial sac and then, more slowly, from the pericardial sac into the chest. You keep mopping and mopping and now, finally, you can see a little bit. In fact you actually think you do see the phrenic nerve there, a yellowish-looking stripe. You extend your incision cephalad (toward the head). You are looking for bullet holes.

“Do you see anything?” J. T. asks from the opposite side of the table.

“I see nothing,” you tell him. “But one of those bullets must have nailed the left ventricle. At the very least.”

More blood, more blood.

“More four-by-fours. Please.”

Someone hands them to you.

There is the hole you have just made in the pericardium, now almost the length of the heart. Beyond, something is twitching. You put your first two fingers of your left hand up against it and gaze up at the monitor. You can feel a faint throb of muscle with each electrical pulse on the screen. It's hard to believe through all this, but it looks as if the heart is still trying to beat.

You've got almost your whole hand on the heart now, and with those first two fingers you reach around the back side of the heart. Gently, and when that doesn't work, not so gently, you deliver the heart through the hole in the pericardium. The heart remains attached at its base to the plumbing, the aorta, the pulmonary artery, but the ventricles have now been swung free, pulled up into the incision site, and the heart rests in your hand, quivering.

Here it is, the naked heart. And even though you've seen this before, even though you think it should be no big deal, it feels absolutely unearthly. The Aztecs did this, plucking the still-beating heart from a victim's chest.

J. T. has come around behind you. You don't have to say anything. He takes the heart, places it between his hands and begins squeezing it by clapping his hands slowly together. This is open heart massage. Again there is blood everywhere. It must be coming from the bullet holes.

Where are the holes?

You move J. T.'s hands away and replace them with your own. You don't look for the holes; you feel for them. Two bullets in the chest. Did they both nail the heart?

You find one hole, then another, both anterior and, you think, both into the left ventricle. Gently you feel around the back side of the heart, and there you find the two exit holes. They are positioned so they appear to have exited from the left ventricle.

“I think I got the holes,” you tell J. T. “Here, get your fingers in here.”