It was a routine Friday night trauma shift, and the team was gathering for what sounded like a TINO—Trauma In Name Only; a rollover MVA with a single driver who self extricated and was walking around at the scene slightly confused but with no obvious signs of injury.
I was sitting at the x-ray computer station when the tech came up and said, “Excuse me Doc. I need to log on.”
I stood and he caught sight of my face. “Oh, hi Dr. Davis,” he said smiling. “I hoped you’d be on for my first shift. I just started here 2 weeks ago, and this is my first time on nights.”
I smiled back, puzzled. He seemed to know me, but I couldn’t place him. He wasn’t one of the regular techs, and I didn’t remember seeing him at the other hospital where I work. His name tag read ‘Larry’, but that didn’t ring any bells.
He nodded and said, “I didn’t think you’d recognize me. Ten years ago, when I was sixteen you operated on me and took out half my liver.”
It came back to me then. He was a good foot taller and at least 30 pounds heavier, but now that he’d reminded me I knew him.
“It’s called Damage Control Surgery. The concept is based on the Navy doctrine of Damage Control on combat ships.”
That night, 10 years earlier, he’d been brought in after being hit by a car while skateboarding. He was in shock and going downhill fast.
We loaded him with volume, packed red blood cells, saline and later, plasma. This was before the institution of the massive transfusion protocol with its balance of red cells and plasma and automatic sending of components at timed intervals. We struggled to keep up with his falling vitals. His abdomen was getting distended and rather than risk him crashing in CT, I did a diagnostic peritoneal lavage. A catheter is inserted into the abdomen through a small incision in the umbilicus, and if you get blood back, it’s a sign of internal bleeding. Not a refined test, and these days, antiquated by the FAST ultrasound scan and the rapid acquisition CT, but back then it was often done if the patient was unstable. Blood bubbled up from my small incision before I could even insert the catheter.
We rushed off to the OR and explored his abdomen. He had cracked his liver through the central sinus, just behind the gallbladder.
Your liver looks like a homogeneous organ, but in fact is divided into right and left lobes by a band of tissue and a central vein just behind the gallbladder. Further segmental divisions are based on the branching of the portal and hepatic veins and although they are real, they are not as well defined. This boy’s liver was smashed. Most of the right lobe was hamburger and the large fracture through the central sinus was bleeding at an alarming rate.
I tried to suture individual vessels, to clip large bleeders and control the bile ducts, but he continued to bleed from almost every surface. Finally, 15 units of packed cells into the procedure, I packed the wound in the liver with bulky gauze pads, compressed the smashed tissue between several other gauze packs and closed the abdomen with the packs inside.
It’s called Damage Control Surgery. The concept is based on the Navy doctrine of Damage Control on combat ships. When a warship is damaged in action, it can’t retire to a nearby shipyard for repairs. The crew must patch the leaks and holes with anything at hand and jury rig systems to function well enough to continue the fight or sail away to safety. So too, when you get behind the physiologic curve in the OR, you need to patch the leaks quickly, staple off or tie off holes in bowel or bladder and bail out with a plan to return another day for definitive repairs once the patient is stable.
The packs controlled the bleeding, and we moved him to the ICU. He got more fluid, blood components and most importantly he got warm. Heat loss in the OR is a major contributing factor to bleeding. By warming him up, replacing the losses, and stabilizing his vitals, he lived to fight another day. Forty-eight hours later, I took him back to surgery and removed the packs, controlled what was now minimal bleeding and removed much of the right lobe of his liver. There was very little new bleeding. He recovered over the next 3 weeks and left the hospital.
Flash forward 10 years, and here he is standing in front of me, 26-years-old, 6.5 feet tall, and obviously in the prime of his young life. He told me he had recovered fast enough that he stayed in his regular high school class and graduated on time. He learned to be an x-ray tech during a 5-year tour in the Army after high school and had just moved back to Arizona with his wife and two daughters, aged two and three.
He still works trauma and general x-ray, and we see each other frequently. It’s not often that I get to see the long-term results of what we do in the trauma bay, but this one is special to me. Larry is a good tech, a nice guy, and when his daughters have come to see him on the job, he looks like a good Dad. Seeing him banishes many of the feelings of futility that I have from time to time.
Bruce Davis, MD, is a Mesa AZ based general and trauma surgeon. He finished medical school at the University of Illinois College of Medicine in Chicago way back in the 1970’s and did his surgical residency at Bethesda Naval Hospital. After 14 years on active duty that included overseas duty with the Seabees, time on large grey boats and a tour with the Marines during the First Gulf War, he went into private practice near Phoenix. He is part of that dying breed of dinosaurs, the solo general surgeon. He also is a writer of science fiction novels. His works include the YA novel Queen Mab Courtesy, published by CWG press (and recently reissued by AKW Books as the e-book Blanktown). Also published through AKW Books are his military science fiction novel That Which Is Human, and the Profit Logbook series, including Glowgems For Profit, and Thieves Profit.
The Website: www.thatwhichishuman.com
The Blog: www.dancingintheor.wordpress.com
