Wednesday, December 26, 2007

The New Math

I'm on call in the OR. The list of urgent and emergent surgeries gets longer and longer. As the day wears on, the anesthesiologists and the OR nurses become weary.

I don't even remember the first operation of the day. At 2:45 AM we finish the last operation. I write out orders to the recovery room nurse for pain medication and send the junior resident to get some rest. I stay to write out the log of the cases that were done on call. At 3 AM my beeper jars my senses. The supervising nurse in the OR informs me that the surgeons are rushing up with a trauma victim from Gaza.

I call the junior resident and tell him to prepare OR 5 for an emergency operation. The surgeons burst in with the patient. It is a Palestinian with a gunshot wound to the abdomen. He underwent an initial emergency surgery in Gaza, but because of ongoing bleeding, the hospital there requested transfer to Soroka for further treatment.

We often get referrals from Gaza, so this was not unusual. The circumstances surrounding the incident were unclear, but the victim was not shot by Israeli soldiers. We assumed that he was injured during infighting among Palestinian factions.

We transferred the young man to the operating table, he was barely conscious, he was cold, and his pulse was barely palpable: all hallmarks of severe hemorrhagic shock.

As the surgeons opened up the abdomen the extent of his injuries was appalling. The bullet entered the right lung, passed through the diaphragm shredding the liver, part of the small bowel and the right kidney finally lodging in the pelvis. Our surgeons admired the Gazan surgeons’ work. They had resected most of the liver, the small bowel and removed the damaged kidney. They anastomosed (connected) the stomach to the stump of the bowel. The sutures were perfect. These guys definitely know how to sew.

Unfortunately, their post-op treatment is less optimal and the patient continued to bleed because of consumption of clotting factors. Although the surgeons urged me to infuse blood, I started with plasma in order to replenish the clotting factors. The only documentation we received described the surgical procedure performed. There was no information as to which blood products the victim received. My instincts were right, the oozing stopped and then I started to infuse blood. The patient’s blood pressure stabilized but remained low. We transferred the patient to the Intensive Care Unit. By the time we were finished, it was 7 AM. Time to sign out.

These “on calls” are killing me. They are becoming harder and harder. Operating through the night has become the rule rather than the exception. Maybe it's the caseload which has become endless, or maybe I'm getting older, or maybe it's both. I go home feeling like I'm observing the world from inside an aquarium.

At the bus stop someone asks me a question, his voice sounds like it's emanating from a tape recorder with low batteries. I haven't the foggiest idea what he wants from me. He points to his wrist. Assuming he wants to know what time it is, I say "7:20."

Apparently I was right because he turns away. I hook up my ears to my MP3 player and try my best to ignore the world. At home, I shower and collapse in bed.

A few days later, I'm assigned to the ICU. Amazing, the patient is still alive, barely. How he survived to the initial surgery is a mystery. How he made it this far is unfathomable. He is sedated, mechanically ventilated, and since his remaining kidney has shut down, is on hemofiltration (a machine that replaces the kidney temporarily). His blood pressure is still low. The doctor finishing his on-call rattles off the vital stats and relates that the patient underwent a "second look" operation to make sure he didn't rebleed.

One of the doctors is a Gazan who tells us the circumstances surrounding the injury. It turns out that the patient was at a wedding. As is customary, shots were fired in the air in celebration. Either someone missed the air in the sky and hit the air in the young man's lung, or it was a bullet finishing its steep trajectory that fell on the unsuspecting victim. Not that it matters to him, but it seems a pretty stupid reason for getting shot.

Ruminating on the case, I became enlightened as to how the "new math" is done in Gaza. I'm reminded of Milo Minderbinder, a character from my favorite book "Catch-22." The character is a mess officer during WW II who turns the war into a lucrative business. He buys eggs at a high price and sells at a low price and still manages to make a profit in a dizzying transfer of goods all over the Mediterranean. This Gazan did the same thing, except with his life.

Bear with me: He was born with nine lives. He used up 11 of them. He still has 2 left. Sounds surreal? You betcha! Surreal is how he survived such a horrendous injury

Post Script: Unfortunately, the patient succumbed to his wounds. This is not only tragic, but frustrating because of all the effort expended to try to save him.


Anonymous said...

What you do is nothing less than miraculous. Whether your patients live or die, what you do is friggin incredible. There must be something in you and your kind, meaning all medical professionals, that is either brain damaged or you posess supreme intelligence.(just a little stupid joke)
I mean, just reading your stuff blows me away. me are amazing!!!!!

Unknown said...

Whoa, easy there big fella. My ego is big enough. There's the (very) old joke about the difference between the LORD and a doctor:
The LORD KNOWS he's not a doctor.

Anonymous said...

Ok, Doc, I prefer Miss. And I still think you are fabulous. I did't say Godlike, I sad fabulous.

Unknown said...

Ah, OK miss. Anonymous is so gender nonspecific.
If I'm only fabulous and not Godlike, than I can only blush and bow. Thanks for the compliment.

No Milk Please said...

i am not sure that i can stomach what you have just described. i go queasy even at imagined blood. best of luck to you and hope you shore up your resolve...

Lioness said...

It's amazing to me how we keep running into the same people at fully unexpected blogs, how on earth did No Milk Please find you??

Unknown said...

It's entirely possible that I left a comment on No Milk Please's blog. I found him through Treppenwitz, to whose blog Iam addicted.

Anonymous said...

i've always rolled my eyes at scenes of men joyfully shooting off guns into the air en masse and wondered how many injuries/deaths were attributable to that activity.



Bongi said...

reminds me of the eternal dilemma between the surgeons and the icu staff about relooks. i've been on both sides of the coin.

great post by the way. it nicely brings across the job. well done.

Jameel @ The Muqata said...

I really need to read your blog more often!


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