sometimes i used to wonder what the students thought of us when we were registrars. one particular story springs to mind that i thought quite humorous.
myself and a very good friend were on call together one thursday night. we got a call from a peripheral hospital. they wanted to send us two gunshot wound patients. the first was a man who was apparently winged and sounded relatively ok over the phone. the second one was apparently his sister-in-law. the doctor informed me that she was 38 weeks pregnant and had been shot in the abdomen. he added that she was in shock and wasn't responding too well to fluid resus. i gave my usual preamble about good lines, catheters and nasogastric tubes. (hope sid schwab isn't too opposed to the use of nasogastric tubes in these cases) and then i told him to send as fast as possible.
i then phoned theater and told them not to start with any new cases until i got back to them about this lady. as i've mentioned in previous blogs, this step would be necessary to make sure we actually got theater time at all for such a patient. i contacted the gynae on call just to give them a heads up and then i went to casualties expecting the worst.
the patient arrived. the entrance wound was on top of the dome of her very pregnant abdomen. she was pale and shocked to hell and gone. to make a long story slightly shorter, soon we were in theater with the relevant bloods and lines etc. we also brought the gynae with us. the gynae brought a paediatrician.
i opened. blood and uterus was all we could see. the gynae removed the baby. on a good day there is a fair amount of bleeding from a caesarian section, which the gynaes seem to take as normal. this time i was very edgy about any extra bleeding. this patient couldn't afford too much. amazingly the baby was still alive but it's maths and science seemed to be severely affected judging by the resus effort the paediatrician was putting in. the other unexpected event was that as soon as the uterus had returned to normal size the liver started bleeding profusely. the uterus had itself tamponaded the liver. soon the gynae was closing the uterus. i meanwhile applied pressure to the bleeding liver. at last the gynae left.
the stomach was shot through. segment four of the liver had also been shot through. the bullet had also transected an aberrant left hepatic artery that the patient had. to be honest at the time i thought it was the main hepatic artery by the amount it was pumping and due to the fact that in these sort of trauma cases it is not always possible to be totally sure of anatomy. the bullet had then entered the posterior wall of the uterus and come to a standstill just posterior of where the baby's head would have been. 2cm anteriorly and the baby would have been hit. once again, to shorten the story, i tied off the bleeding artery, closed the stomach, tacked the liver as best as i could and packed the rest (this is part of dammage control surgery, the principle being that you at least stop the bleeding and get the patient to icu to try to better her condition for a more definitive procedure. the packs are supposed to keep pressure on the liver and thereby prevent bleeding. in this case, because the abdominal wall was so distended from the pregnancy, the packing applied little pressure and caused us endless stress later on. to the credit of our icu, they managed to reverse her coagulopathy and to stabilise her hemodynamically) we took her back after 48 hours, removed the packs and just made sure there was no further calamity. the liver looked fine which was quite a relief to me.
and then the icu phase started in earnest. the woman developed a severe sirs response. her lungs fought our attempts to ventilate them, her whole body swelled up with fluid which leaked out of the vascular system, her heart was reliant on industrial doses of adrenaline and her kidneys tethered on failure for just over a week. after probably a month she slowly began to improve. her recovery from then on was slow but steady and finally she was sent to the normal ward. there we pampered her further. we got to know her quite well and finally also heard the story of the shooting.
her husband was the owner of a taxi business. now in south africa that is nothing like what people in the first world may be thinking. a taxi is more like a mini bus service, completely without government control, which means more often than not they are controlled by somewhat less than savory people. anyway, one of the rival businesses decided to do a hit on him. the night in question they broke into his house and blazed away. the target was killed on the spot. his pregnant wife ended up with me and his brother who happened to be visiting picked up a lead trinket in his arm.
with each new group of students we would proudly describe her wounds and how we had pulled her through. we stopped short of openly bragging, usually.
finally the time of discharge drew nearer. but because she had had such a torrid time and because we had become quite attached to her we postponed it as long as possible. we eventually told her we would discharge her the next friday.
the thursday before once again we were on call (we were the thursday firm). that night we admitted a guy who had had too much to drink and presented with a bit of bloody vomiting and mild pain. a touch of sucrulphate and he was fine. the next day we got an entirely new group of students. most students fear the surgical rotation and these were no exception. they timidly followed us around on our ward rounds, trying not to draw too much attention to themselves. we got to the alcoholic gastritis guy. the students obviously had no idea what was wrong with him. i examined his abdomen and casually told the house doctor to discharge him via gastroscopy. he turned to me and said "thank you doctor, you saved my life!" my friend and colleague started laughing. i think i might have chuckled. we turned away both saying under our breath things like "yeah right" and "what a moron". the students i'm sure thought that surgeons are a lot worse than the stories about them.
then we got to the gunshot woman. we casually told her that it was time to go home. she turned to us and said "thank you doctor, you saved my life!" i could almost feel the students cringing for the expected aggressive response. how surprised they must have been when my friend and i both stood there biting back the tears.