Wednesday, November 7, 2012

Bloody Sunday: Trauma # 4010 and 4011

Sunday was shaping up to be a pretty nice day. I taught an airway class in the morning to some of the medics and planned on taking it easy for the rest of the day. However, at almost exactly 12 noon we received the call - 2 Afghans shoot in a Taliban ambush. The initial reports were a bit sketchy, but it sounded like one patient was shot through the neck and critically injured and the other was shot in the back and was described as stable. 

Twenty minutes later the MEDEVAC helicopters arrive. I place myself at the "Triage Line" so I can get a good look at the patients after they are unloaded from the helicopter. Patient 1 was in fact shot through the upper right chest - not the neck. He has an intraosseous catheter in each leg - which is my first clue this guy is in trouble. His skin is gray. Clearly, he is in bad shape. The patient is directed to trauma bed 1.

Next off the helicopter is my casualty, patient 2, the gunshot wound to the back that was reported as being stable. He looks awful. His skin is an even more ominous color of gray than the previous patient. He is barely arousable. I ask the flight medic what medications the patient has received - hoping his altered level of consciousness is secondary to narcotics - the medic tells me no medications were administered. It's obvious to me at the point that this patient is in decompensated hypovolemic shock. He is dying. 

I help push patient 2 to trauma bed 2.  IVs are quickly established and he is placed on my monitors. I am pleasantly surprised to find a decent blood pressure. I intubate (put a breathing tube in) the patient after inducing anesthesia with Ketamine and Succinylcholine. I secure my breathing tube and look at the monitor. He doesn't have a blood pressure any more. He is now in Pulseless Electrical Activity (PEA) - which means that his heart is no longer pumping blood. We start CPR and do all of the things you do when someone's heart stops. After a few minutes of CPR and some drugs, we get a pulse.

Emergently, we take patient 2 to the OR in an effort to find whatever is bleeding in his abdomen. However, by the time we get him to the OR table his heart stops again. We start CPR and the surgeon decides to perform a resuscitate thoracotomy. His heart is empty and the only chance this patient has for survival is opening his chest and manually compressing the aorta while performing cardiac massage. This is the definition of a last ditch effort. His odds of survival are literally almost zero at this point. Fortunately, this "Hell Mary" intervention buys us some time. The surgeons now direct their attention to the abdomen, which is the most likely site of the internal hemorrhaging. His abdomen is opened in seconds. Copious amounts of blood, essentially his entire blood volume, pours out of the incision and on to the OR table and floor. The injuries to his internal organs are numerous and devastating.

There is a difficult decision that needs to be made. We have only a finite amount of PRBCs (transfusable blood) available. The other casualty, patient 1, has a serious chest injury and will require a massive amount of blood as well. However, statistically speaking, he has a much better chance of survival than my patient. Do we classify patient 2 as expectant and allocate all of the available blood products to patient 1, or do we make an effort to resuscitate both patients? Quickly, literally in a matter of moments, we decide to continue working on both patients. We notify the lab that we will start using whole blood obtained from soldiers on the FOB with compatible blood types. A call goes out to the entire FOB. Within moments we have 40 soldiers waiting to donate blood. Luckily, I and am able to place both an arterial line and a central line in the patient rather quickly. The transfusion of whole blood is given at such a pace, thanks to the expertise and skill of our medics, that I give up trying to keep track.

When it is all said and done, we transfuse over 20 units of blood products to my patient. We have to take him to the OR twice in order to control his bleeding. Remarkably, his blood pressure starts to normalize and the oozing of blood (from everywhere) begins to slow down. Everyone, including myself, is astonished that he made it out of surgery alive. By midnight patient 2 is on his way, along with patient 1, to Bagram in a helicopter. Somehow, against all odds, the guy makes it out of FOB Sharana alive.

Both of these patients have no business surviving those injuries. Their survival is a testament to the skill and expertise of the 691st FST - a unit that has been in Afghanistan for less than two weeks.

Approaching "Dust Off" carrying trauma # 4010 and 4011

Patient 2, my patient, shortly after emergency thoracotomy. Obviously, this photo has been heavily edited.

This is the nearly pristine 7.62mm projectile found in the abdominal cavity of my patient.

This is a large segment of Patient 2's liver.