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Emergency medicine is characterized by hours of routine punctuated by moments of terror and then back to routine. We must manage a crush of humanity with routine problems and sort out the critically ill from that chaos, constantly balancing the need for completeness against the need to move on. The critically ill cannot wait for us to do complete comprehensive evaluations on the twenty preceding patients and they are often unable to provide complete information about themselves. Interventions required may be so urgent that even a “hello” is hardly possible. I’m always wondering, when backed up, if the tenth or twelfth patient down the line might be such a person who somehow was mistriaged. When such urgency is needed, we act and react with frighteningly incomplete knowledge of what is happening. Some comfort can be taken in reciting simple mnemonics such as “ABC.” These rote routines help to keep us grounded and organized during moments of panic but I cannot help to admit that the gravity of some of our decisions weighs heavily with me.
Emergency medicine sometimes requires being astonishingly aggressive. For example, before RSI intubation techniques were common in the ED, we were encouraged to have a comparatively low threshold for cricothyroidotomies in trauma patients. It has been years now since I felt the need to perform such a procedure. There is progress! It was and is a procedure which I dread: unpredictably bloody and always feels like murder, cutting someone’s neck. Plus it is a procedure for which little time can be wasted balancing the pros and cons – do it right now or don’t bother because the outcome of a delayed procedure might be worse than death. Weighty decisions. Little time.
Another aggressive procedure which we are performing less and less: open thoracotomies in the ED. It is generally such a futile procedure that in the gallows humor of the ED it is referred to as, “should we do the autopsy now or do it later.” By the time anyone can ever get around to performing the procedure it is already too late. Nevertheless, I felt in my early years that I should have some rudimentary knowledge of how to do this because “you never know what might walk through the door.” I learned the basics of this at the side of a colleague who is now long since deceased. Of course every one of the few patients for whom I saw or performed this procedure died. Arguably they died before the procedure.
Ten to fifteen years ago, while working early morning in a suburban community hospital ED, I had a 13-year-old child stumble through the ambulance entrance on his own feet. An adult was shortly behind and described how the child had popped the clutch on an ATV four wheeler. The four hundred pound machine reared up and landed on the child’s chest. This child collapsed before us and was instantly in extremis upon arrival through our doors. A quiet early morning ED was suddenly a disaster and there wasn’t even an ambulance – they appeared out of nowhere. I was the sole physician in the entire hospital, let alone the ED. Thanks to some very capable nurses assisting, we had the child intubated and large-bore IVs established very quickly with fluids running in. The child was and remained pulseless and unresponsive despite quite normal cardiac electrical activity. I rapidly made what was in retrospect a bizarre decision. Something had to be done quickly. Do it now or do it later? Do something else? Just do something for God’s sake. Everyone knows that opening the chest of a blunt trauma victim in the ED is even more futile than penetrating trauma and frankly they are both pretty futile. But that is what I did. An open thoracotomy in the ED on a blunt trauma victim, a child, without surgical backup.
If I’d ever thought a cricothyroidotomy felt like murder, it was nothing compared to this. A silly spash of betadine, a nonsterile field, and his left chest was ripped open in seconds. As usual for such a procedure, there was no bleeding. The patient was already dead. But this child’s heart was still beating just as his monitor strip would have us believe. I opened his pericardium and delivered the heart through that incision only to be confronted by something I had never experience or expected. Like someone had flipped a light switch, I suddenly had bleeders. The heart, freed from the tamponade, was able to pump and perfuse freely once again. A few well-placed hemostats and…..
Now what? I have no surgeon, let alone thoracic surgeon. I have absolutely no ability or skill beyond this point and one could argue I didn’t have any to even get to this point. What have I done?
We flew the child out by helicopter to the nearest trauma center with chest open and hemostats in place. I kept up with his progress for awhile. He spent three weeks on ECMO (heart lung bypass). An early CT scan of his brain showed “watershed infarcts” which then cleared up on subsequent scans, an indication of how close he had come to very serious irreversible brain damage. If only a minute or two longer down time and who knows what damage would have been done. After 1-2 months in the hospital, he was discharged home, neurologically intact, fully functioning.
Several years later, the child’s aunt visited me in the ED to tell me he was in high school and doing well. I still remember his name and face as clearly as if it were yesterday. Sometimes I try to picture the horrible scar that I must have left across his chest, the lumps where I cut his ribs with trauma scissors. I think back to what an old friend once said to me, “Better a lucky doctor than a smart one.” I honestly don’t know, if confronted again by similar circumstances, if I could do such a thing again. And perhaps that is a good thing. Despite the success, I managed to seriously frighten myself. If I were at all comfortable with what happened, I would be dangerous.
Charles Grassie, MD