Friday, June 27, 2008

The "eyes" have it.

The last on-call was full of action. But there is such a thing as too much of a good thing. The phone rang from the trauma room. In ten minutes a blast injury victim will be brought in. For the third time this month a Bedouin has "encountered" an unexploded shell. These are not citizens innocently exploding. These are criminals who knowingly risk life and limb and enter the army's training fields for one of two reasons: One is to strip old armored vehicles used as targets for their iron and sell it (iron prices have skyrocketed recently). The other is to try to retrieve explosive material from unexploded ordinance to sell to the terror organizations.
A 51 year old semi-conscious man was brought in. Full of shrapnel holes, right leg broken, a finger or two mangled, left eye looks like mush, pools of blood forming around him and most importantly an expanding hematoma in the neck. While the surgeons examine him I ask the nurses to prepare the intubation tray and as an afterthought, "have the emergency tracheotomy tray on standby and page the ENT guy to get here now!" The drugs are in and the patient loses consciousness. Opening the mouth with the laryngoscopy my instincts were right: the hematoma in the neck obliterated the anatomy so I can't see the vocal cords. I try a blind intubation and miss. The ENT guy runs in. "No go, you'll have to perform an emergency tracheotomy." The cricothyroid membrane identified, an incision made and the tracheotomy tube passed into the trachea. The patient is stable, there is no evidence of internal bleeding so we transport the patient to radiology for a total body CT. Except for the bleeding in the neck there is no evidence of additional bleeders. There is shrapnel all over the head and neck including two in the brain with no hematoma or edema, so no need for neurosurgery. In the operating room, two teams work simultaneously. The orthopedic surgeons internally fixate the broken tibia and the ENT surgeons explore the neck. They find lacerated lingual and facial arteries only millimeters from the carotid. A millimeter in the wrong direction and this man would have died even before being evacuated. More luck than brains, that's for sure.
It's midnight, I've been working on this guy for 8 hours. ENT and orthopedics are done. We transfer the patient to the ophthalmology OR (their special operating microscope can't be moved so we must bring Mohamed to the mountain in this case). The policy is to try to repair the eye even if it isn't functional, for aesthetic reasons. It's going to be a really long night. The surgeon begins the tedious process of suturing the eye with ophthamology's Amazing Invisible Sutures (tm). These sutures can't be seen with the naked eye and to tell the truth I don't believe that they are actually there. Oh wait, the TV monitor is hooked up to the microscope. They really are suturing what looks like a bowl of jello.
"That's the eye?" I ask.
"Yup, that's it."
"And it's going to look like an eye?"
"Yup, in about 3 or 4 hours."
(Talkative, aren't they?)
At three AM I literally can't keep my eyes open (ironic isn't it?). I drink some water, walk around look at the mush on the TV screen, hey, it's starting to look like something. Every time I sit down, I fall asleep. OK so I won't sit down.
Four AM, we've been at it for 12 hours. I call up to the general OR where they've been busy too. When we finish the next case, an amputation, we'll send someone to relieve you.
Five AM, hooray, they've finished the eye and my relief walks in. I run down the injuries and surgery that's been done. Now all that's left is to suture the eye lids ("only" 4 more hours of work.) "Good luck, I'm going to get some rest".
The next day is for recovery from the on call.
More or less rested, I come in to work. I've been assigned to urology. The first case: A five year old scheduled for uretheral implant (she has a double system from her left kidney and so she "leaks"). The problem: she was born with Transposition of Great arteries (that's where the main arteries arising from the heart, the aorta and the pulmonary, are reversed). She had corrective surgery, but she still has residual defects that might complicate major surgery. Everything goes well.
The next case is exploration of the retroperitoneum to excise a tumor. These operations are usually accompanied by significant bleeding. After inducing anesthesia I put in a big IV line and an arterial line. The surgeons are having a tough time exposing the tumor (previous operations resulted in adhesions), but finally expose it. There was about a 1.5 liters of bleeding but adequate fluid rescucitation and only one unit of blood later the tumor is out. While closing I administer morphine for post op analgesia. I wake the patient and extubate.
The surgeon (the chief of Urology, no less!) Thanks me. "It's good to have you on board, it gives us peace of mind which is important in such a tricky operation."
Wow! Surgeons are notoriously stingy with compliments, so this is a rare occurance.
It's nice to be appreciated.

1 comment:

Lioness said...

Loved it, despite the vilage idiot.

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