so i've just come into theater to find a terrified medical officer and a patient who seems just about to cash in his chips and leave this life. i immediately splayed the hole in his neck, allowing him to breathe a bit. when non medical people think of these sort of situations i often imagine they have this idea of smoothe control and everything happening beautifully. it is not usually so. sometimes the whole thing looks pretty messy. with this man, as soon as i opened his neck he gave a greatful gasp followed by a bloody cough....all over my face. (this is actually why we wear masks). my glasses were splattered with frothy blood, but i was just too glad the guy was breathing.
once again i attempted to insert the trachi tube, but because his trachea dropped back so sharply and so deep i couldn't get it in. (it is a fairly rigid c-shaped pipe) i decided to attempt intubation through the hole with a normal endotracheal tube which is much more flexible. this worked and we all breathed. (funnily enough it seems it wasn't just the patient having trouble breathing)
i degloved, told the medical officer to put the man in icu (he told me there was a bed they could make available in about an hour) and i left. this time i didn't have a beer. it was too late.
i started this story by saying there were a number of reasons i wanted to discuss the post. i'll attempt to now without being too disjointed or tangential. the first thought once again has bearing on the discussion about the almost military like training of surgeons (where i come from anyway). i read a comment in one of the posts about a surgical registrar who turns his cell off when he's not on call. we were never permitted to do that. i was not on call during the events described above. i have no doubt that the patient would have died during his first tracheostomy if i had not gone in. once again, because of some crazy decisions by the province i will not be paid for the tracheostomy or the reintubation or going out at night. so although i do not actually believe in the brutality of our training, there must be some form of ballance. surgeons produced must be able to work inhumane hours and still function if necessary, especially in our setting where there aren't too many of us. when a surgery patient complicates it is often rapid and dramatic. it usually can't wait for the morning. i'm not sure what will bring ballance to the force though.
the next thought had to do with my reaction to the events of the second intubation and the medical officer's reaction. as i said when i arrived he didn't seem to be having too much fun any more. i almost wondered if i should first resus him before i turn my attention to the patient. i realised that this job is not for everyone. i actually enjoyed the challenge of the difficult trachi and the intensity of the whole situation. maybe i'm a bit of an adrenalin junkie. the medical officer felt the responsibility of trying to keep this guy alive when he seemed so determined to die was more than he could take. that's why i spoke in a previous post about the fact that we are not working with surgeons and need to treat them more gently than what we sometimes think is needed. there is also the whole arguement about what this type of stress does to people who are not built for it. when i started this blog i spoke of another blog by a suicidal medical student (http://other-things-amanzi.blogspot.com/2006/11/thoughts-etc.html). the guy should never have done medicine. all the horror of our daily work was killing his humanity. i really felt for him. but at the same time the fact is these gunshots or assaults or stabs or whatever are going to happen. people are needed to deal with them. i've often thought about a debriefing or trauma counselling for surgeons, because sometimes i think it is needed. unfortunately i think macho surgeons would scoff at the idea. but maybe the stereotypical bombastic surgeon is like he is as a defence mechanism??? maybe sometimes to remember that these maimed, broken, stinking bodies that we deal with daily are all as human as we are challenges our own mortality too much. it is difficult to be confronted by one's own mortality, but to be confronted a few times a day seems more than a lot can take. one of the greatest things for me about surgery is to return people to their humanity (see http://other-things-amanzi.blogspot.com/2006/11/perianal-absess-connection.html) maybe this is my way of avoiding what i see as the pitfall of forgetting the humanity of those dying around you. what does a soldier do in the heat of battle i wonder?
anyway, all very melodramatic. i did warn it would be disjointed.
the conclusion of disaster was only revealed the next morning and i'll leave that for another post.
so once again, to be continued.