A coal truck rolled off the road and down the mountain. The 60-year-old driver was ejected and pinned under the cab protector with the weight of the truck crushing his upper thighs and a pile of coal covering the rest of him. The firefighters worked 45 minutes uncovering him and jacking the truck up off of him. The coal truck was a giant tampon, controlling the bleeding until the truck was lifted off his mangled legs. The medics quickly applied tourniquets which didn’t work nearly as well as the truck, because they forgot a basic rule of trauma: cut off all clothing.
The jeans interfered with the tourniquets so that he was bleeding heavily for half an hour while being transported to us. They rolled through the doors pumping chest. This violated another rule of trauma: do not attempt to resuscitate a trauma patient without a pulse, because it never works.
One possible exception to this rule is a “witnessed arrest” meaning that the pulse was lost during medical monitoring. But if medics find a pulseless person at the scene of an accident, they do not start CPR. This was a witnessed arrest and so the medics worked him.
I thought, “This guy’s got a snowball’s chance in hell.” All the blood that was in him was on him, so that he was white like a snow cone covered in strawberry syrup. I suppressed the urge to pronounce death and send a nurse on a midnight run for McDonald’s strawberry sundaes for all, and we all ran into the trauma room to work this poor feller.
I rubbernecked at the mangled legs like a driver who can’t maintain speed past a mangled car on the side of the road, as I walked to his head to evaluate his airway. Airway is almost always first. It’s the “A” in “A,B,C.” “B” is for “breathing,” and “C” is for “circulation.”
The medics had placed a temporary “King” airway which the respiratory therapist was managing, and so I barked some nursing orders as a medic pumped chest and I checked the tourniquets. I noticed the jeans were scrunched under the straps, but there was minimal bleeding and so I went back to the airway.
We had a great team that night: the best surgeon, nurses and technicians. I have never seen so much blood and fluids given so rapidly. As I finished replacing the temporary airway, all the blood we were giving him started pouring out of his legs as the chest was pumped.
It was then that I realized the tourniquets were not working. The reason he was not bleeding when I first saw him was that he had no blood left to bleed! But now the blood was coming out his legs as fast as we were putting it in his veins, like trying to fill a holey bucket.
As I removed and replaced the tourniquets, I had to work around his genitalia. It seemed odd to me that his genitals were completely unharmed while his thighs had been reduced to pulp.
After I clamped and tied bleeding arteries and veins, we felt a pulse, but he didn’t twitch or open his eyes. I told the student looking over my shoulder, “This is why we don’t work traumatic cardiac arrests. If he wakes up, he will be missing his legs and half his brain function.”
“But at least he still has his nuts,” I thought to myself with a grim smile.
I felt guilty as he was rolled off to surgery. I thought, “You dumb ass, look what you’ve gone and done now!” This was not the only time I felt guilty for saving someone. I often walk out of a save thinking the only rationale for what I did was to bill the patient for one more day of torture.
I went to find the family. “This discussion would be a lot easier if I he was dead,” I said to myself. It looked like a midnight family reunion in the “Bereavement Room.” There was a large family in there with the courtesy snack cart anxiously awaiting me.
I always err on the side of bad news when painting the picture for families. If a patient dies after you painted a rosy picture, then the family will be angry, as if the doctor broke a promise. But if it sounds like all doom and gloom, then they are thankful for almost any outcome.
This is the source of many prayer meeting miracles. “The doctor said he was dead, but here he is!” I feel a little guilty for not giving people more hope in the moment, but they are more satisfied with the results.
By some miracle this guy woke up after surgery neurologically intact! But he was angry at us for saving him. He said he would rather be dead than in a wheelchair.
A few months later he realized he was grateful for the opportunity to see his grandchildren grow up and he is enjoying life again with his genitalia intact.
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