Valentine's Day 2017

​The pager went off at 6:42 pm. "Full Trauma -- ED 6"

I hurried down the stairs and into the Trauma Bay. Several team members were assembled around the room

"What have we got?", I asked.

"24 year-old male, GSW to the chest. CPR in progress". (GSW = Gun Shot Wound)

"Get the thoracotomy tray. Have we called Blood Bank?"

"A box of blood is on the way. EMS three minutes out."

We heard the stretcher coming down the hall. A moment later, the unconscious patient was lifted onto the gurney. Nurses and techs went into action: placing EKG leads, starting additional IVs, stripping off blood-soaked clothing.

"What has he had?", I asked the medic.

"This is liters two and three of lactated ringer's. We've given epinephrine twice. He's in PEA."

"Stop CPR.”

​I felt for a pulse at the carotid artery and there was none.

The monitor showed an electrical rhythm but there was no pulse, likely because there was insufficient blood in the vascular system to generate an adequate blood pressure.

"Resume CPR."

"Rapid infuser is ready," said the trauma nurse. "How much blood do you want?"

"Hang a unit of cells and keep it coming, alternating with plasma every two units."

Meanwhile, I had opened the surgical tray and grabbed the scalpel. With one long, smooth stroke, I made an incision along the upper edge of the fifth rib from sternum to armpit, slicing through skin and fat down to muscle. I traded the scalpel for scissors, cutting the muscle between the ribs to enter the chest cavity. I could see pink lung tissue inflating and deflating with every squeeze of the AMBU bag.

"Stop CPR.”

The chest compressions were obscuring my view of the pericardium, the tough sac that contains the heart. When they stopped, I could see it was distended with blood which was crowding out the heart so it could not fill and pump. I cut a hole in the pericardium with the scissors and blood rushed out- over the lung, out of the chest, off the gurney, and into my shoe. There was clearly a large hole in the heart or one of the large vessels associated with it.

"More blood! Keep it coming!”

I took up the scalpel again and extended the incision across the sternum and onto the right side, an exposure known as a "clam shell". I now had access to the entire chest cavity, which was held open by a Medieval-looking instrument called a "rib-spreader".

The heart was not beating, and it was flaccid and flat- EMPTY. Blood was pouring out of a hole at the junction of the inferior vena cava and the right atrium. I put a finger over the hole. The heart filled and began to beat weakly.

"Suture!"

With my left index finger on the hole, I took the suture in my right hand and started sewing. Meanwhile, the nurses continued pumping warmed blood into the veins. As I completed closing the hole, the heart began to beat more strongly. The monitor showed a rapid but normal rhythm. Blood pressure rose. A sigh of relief went around the room.

"Call the OR- we'll have to take him down and get him closed. Do we have an ICU bed ready? Let's get a set of labs. Warm blankets, please. He'll need a Foley catheter and a nasogastric tube."

We'd done it. Life saved.

"Family is in the consultation room," said the Chaplain.

I looked down at myself. I was a mess: arms smeared with blood to my elbows, scrubs soaked with blood from chest to knees.

"I'll have to change before I talk with them."

Someone ran to get me a clean set of scrubs and I set about washing up at the sink.

"Pressure is falling again!", announced the trauma nurse.

I turned from the sink.

​“Check for a pulse. Give epinephrine. How much blood has he gotten? Do we have labs yet?"
​
The respiratory therapist read off the numbers. They indicated sufficient blood volume and oxygenation, acceptable acid/base balance and electrolyte levels.

I looked back at the heart. The sutures were intact and there was no bleeding. The heart was full, but barely beating. I began rhythmically squeezing the heart between my hands to augment its contractions. Soon, they ceased. Medications to stimulate heart activity were administered, I kept pumping, and we spent another twenty minutes working with no recovery of spontaneous heart function.

"We've lost him.", I said.

I continued manually pumping the heart while verbally running down the list of what had been done so far, what the current status was, then polled the room.

"Is there anything more we can do? Can anyone think of anything we've missed?"

No one could.

"I believe we have reached the limits of what we can do, so I propose we discontinue resuscitative efforts. Are there any objections?"

There were none.

"Time of Death: 7:51 pm.”

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