Surgery - Shots Fired

Updated: Nov 25, 2020

By the end of the third week of surgery I had still not seen a good trauma come in. There was one girl who got shot in the leg, but it was nothing too exciting. I had one last chance to see something good. My last call was a Friday night before exam week, and I was working with Dr. D for the first time. I had heard a lot about this guy, he was the young rising star of trauma surgery and was doing things that was making heads turn in the business of resuscitation. I also heard he is just overall a cool dude and easy to get along with so I was pretty excited. Plus unlike the other surgeons that always hoped for an easy slow call night this guy was blood thirsty. He lived for the thrill of a fresh gun shot wound.

Around 10pm that evening the trauma pager went off and the text message from the ER read “17 year old male, GSW to abdomen, hypotensive”. Which meant that a guy had been shot somewhere in the abdomen and was probably bleeding out. When I got to the trauma bay the patient was still en route. When a trauma comes in there is a well rehearsed dance that involves about 15 people ranging from nurses, ER docs, and the surgical team on call. Every one has a specific role and many things happen at once. The patient's airway is accessed along with breathing, circulation, and any other injuries that may be apparent, all the while IV’s are being started as well as what ever vital signs and labs are needed. My job as a med student is to stand back and try to catch information as its being yelled out and document it on this rather lengthy trauma sheet.

This guy was in rough shape, there was only one bullet wound with no exit wound just underneath his diaphragm on the left. After the initial assessment it was quickly determined that he was crashing and needed to be rushed to the OR for exploratory surgery in an attempt to stop the bleeding. As I remember it was myself, another doc, and a random nurse that wheeled this guy up to the OR on the 2nd floor. There was a moment when we were in the elevator going up when the thought raced across my mind, “what if the elevator gets stuck and we have to cut this guy open right here and now”. Thankfully as soon as that panic set in the elevator doors opened. In the OR there was no time for delicate precision and pretty incisions that is usually the norm. This guy was pretty much filleted open from his sternum to his pelvis. Blood was every where, and there was a mad rush to find the bleeding. The bullet had clearly gone though the liver, pancreas, and part of the stomach, but that was not all. As the search continued it was determined that the bullet had also gone through some major arteries that supplied organs. Those arteries had to be close off and the organs taken out. This involved taking out the spleen, left kidney, and half of the pancreas. Maybe it was a little twisted, but it really reminded me of playing operation when I was little. I was waiting for the funny bone to come out, or the butterfly in the stomach. The whole time this was going on I was standing next to Dr. D holding a retracting blade as hard as I could so they could see the field. Occasionally I would cut a suture or hold back the intestines as they fixed blood vessels that were underneath.

It was a bloody process and in the end we had slowed the bleeding down considerably. At one point in the operation Dr. D turned to one of the other med students that wasn’t scrubbed in and asked her to go into his bag that was in the corner and get some package and give it to the nurse. It was some sort of sterile package with foam like material inside. He cut part of it off and stuck it in this guy’s belly. When I asked him later he said the military gave it to him, and it causes a thermal reaction that coagulates blood upon contact. So basically this guy is such a bad ass that he brings his own gear into the OR.

In the end the guy lived, or at least was still alive when I was finished with trauma surgery a week later. Unfortunately it turned out the magical bullet was not done with him, in addition to shredding a good amount of organs it had lodged itself in his lumbar spine crushing one of the vertebral bodies and causing him to be permanently paralyzed on his left side. So there are two lesions to be learned from this story. One, don’t do things on the streets your not supposed to be doing, or you’ll get shot. Two, if you are going to get shot, pray that it’s a fairly large caliber bullet, and not something like a 22 that will just bounce around inside of you like a ping pong ball. To further illustrate that point a patient that came to trauma about a month before I was on had been shot in the pelvis. The bullet ricocheted off his iliac crest and found its way into his aorta in his chest. From there the bullet traveled in his blood stream like some kind of confused piece of cholesterol and eventually lodged itself back in his pelvis, but this time plugging up the blood flow and causing hypoxic damage to his thigh. The official diagnosis was bullet embolism.

In the end I was glad I got to see what I had signed up for even if it was my last night on call it was still a pretty amazing experience. I have a lot of respect for the guys that do this kind of stuff, I don’t think I could ever it myself, but I can admire those that do.

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