Blood stains and bleach

It only takes one patient to make your call night busy.

I was already four consults deep when they called a code trauma. Man fell from 30 feet onto his head, GCS 3 (basically non-responsive). Well this can't be good. Usually when I get the trauma page I like to place bets on the likelihood of me actually having to stay and being involved. When he rolled in on the gurney, blood gushing from his forehead and spewing from his mouth as he was being mask ventilated, thoughts of catching a quick afternoon nap eloped with my appetite and the adrenaline kicked in.

Face shield. Isolation gown. Gloves. Neuro exam. I made my way to the head of the bed and tried to pry open his eyes, already swollen from his multiple facial fractures. Minimally reactive. No response to verbal command. I made my way down to his arms, no fractures... he must have broken his fall with his head. No bueno. He didn't flinch when I mashed on his nail beds, poor prognostic sign, and likely indicator of spinal cord injury. I went back to the head of the bed to see if he was responding any more, and was quickly recruited to help secure the airway. The ER docs had their hands full as blood gushed out of the patients mouth like a geyser. I bag masked the patient as they prepared for the intubation, and found my facemask splattered within seconds. The patient's jaw was crushed, making the intubation tricky, but they got it and we rushed him next door to CT. I took off the isolation gown to find that my white coat was splattered like a bad Jackson Pollock. Damn... I had just washed this.

His CT didn't show too much intracranial blood, but the bony damage was horrific. It looked like the front of his skull had exploded, and the number of disjointed bone fragments floating in the soft tissue of his face were too numerous to count. He wasn't going to do well, but with active bleeding from his face and abdomen we had to give him a chance so we rushed him to the OR to fix the abdominal bleeding first. The trauma surgeons cut him open and repaired what they could of the liver laceration they found on CT, and packed it with gauze to tamponade the bleeding and closed with ioband (a sticky film like seranwrap) knowing they'd have to go back in after the bleeding had stopped to remove the packing. He needed intracranial pressure monitoring though since we didn't have an exam. While they were finishing up I shaved the head and cleared out a sterile space to place my ventriculostomy. By the time I was making incision the trauma team was done so I had an audience of about 15 people. Crap. I don't remember ever being nervous about placing a ventriculostomy, but just having a panel of other residents watching you is pretty intense. His skin was 2 cm thick from the swelling, and cutting down felt like I was slicing into a bad steak. I drilled cautiously given all his skull fractures, and luckily the bone I found didn't sink in while I was boring out my entry hole. I passed the catheter and squirt, the CSF burst out. Whew. First pass. Way to shine when it counts.

After some angio embolization of his liver bleeders we got him to CT again. His brain had burst into a bloody mess, and with his physical exam findings his prognosis was very poor. We got him to the ICU and I was notified that his family was waiting in the surgical waiting area. This was going to be a difficult conversation, but I had told family members bad news before. I guess I just wasn't ready for a whole family. Sons, daughters, wife, nieces and nephews were all there. I told them what had happened... what we had found... and what he was like now. The eldest son was the spokesperson. As I told him the news, he didn't cry, but you could see the helplessness fill his face as the reality of the situation was painted so dismally before him. The faces of the women who understood English started to flush... and the eyes of those who didn't looked around anxiously wondering what was wrong. I told them they could see him soon in the ICU, and left the area and walked out of the hospital into the cold night air, somewhat overwhelmed by the collective sorrow I had just stirred. God my job sucks sometimes, I thought. There wasn't anything we could do, I told them. We weren't going to offer surgery because prognosis was so poor, we had decided. I agreed with our decision, but knew they didn't understand the why of the situation. When the wife was finally at bedside, wailing for her husband to wake up, to open his eyes though they were swollen beyond human recognition, and then kissing his dusty feet lovingly, washing them with her tears as we only read of in scripture, I thought to myself again, man my job sucks.

Before I left the next morning, I sheepishly skirted past them, ashamed that I had breached the topic of withdrawing care given the situation. But realizing I was being an idiot, and that they needed whatever support they could get, went back and asked them how they were doing and if they needed anything before I took off. Neurosurgery is a field of hopeless situations. But again, I guess it's about making hope when there is none, comforting when all life delivers is despair, and being the kind angel of death when the gates of heaven and hell open with their unrelenting beckoning.

Afterword: I spent an hour trying to wash the blood out of my white coat. Hydrogen peroxide and toilet bleach seem to work pretty well...