Here’s another heavily modified piece from my surgery blog. Entering the Trump era, I need time to let it sink in.When I picked up my laundry I’d have a little small talk with the proprietor. She always called me "Doctor.” This time, though, she was notably distant, which I didn't understand till I got home and hung up my jacket. On the inside she'd pinned an envelope, into which she'd put a photo taken months before, forgotten in one of my pockets.
What it showed was a young female torso bearing sixteen stab wounds and the handle of an 8-inch butcher's knife in-stuck to the hilt, a couple of inches below her left breast, ticking, when the picture was taken, with every heartbeat. She’d tried to make herself the second person she killed that day. A cop had accompanied us to the OR.
Worried that I could cause a catastrophe if I did it blindly, I hadn't removed the knife in the emergency room; the officer needed to maintain "chain of custody." I opened her belly first: with stab wounds to the lower chest, it’s likely there are injuries within the abdomen. Indeed, the knife had skewered her stomach, barely missed her colon, stopping with its sharp edge whispering to her spleen. Holding the spleen out of the way, I withdrew the knife, handed it off to the cop, cool as Steve McQueen: calmly cutting the lady open in front of the officer, handing him the weapon like I did it every day. He tagged it and bagged it, like he did it every day.
As I attended to the abdominal injuries, the anesthesiologist announced blood pressure zeroing out, cardiogram widening into a functionless sine wave. In the ER, I’d treated her punctured lung with a drainage tube. Now I guessed she’d nicked her heart as well. With no time for tidy entry, I made a fast and ugly, trauma-center-trained, trap-door opening through her ribs. Expecting a blood-filled pericardium, the sac around the heart, I opened that, too, carefully, despite the urgency, to avoid paralyzing the nerve to her diaphragm, which runs along its surface.
A cut lung can allow air into the pulmonary veins, through which it returns to the left ventricle of the heart, wherefrom it gets pumped out to the body. Departing first from the aorta are the coronary arteries; an air bubble there acts no differently from a blood clot, potentially causing a heart attack. The next exits lead right to the brain.
While requesting (or screaming, I don’t recall) that the anesthesiologist tilt the table head down so bubbles would rise away from our patient’s head, I clamped the aorta downstream from the vessels going there, called for drugs to raise her blood pressure as high as safely possible, and to run 100% oxygen (in addition to protecting tissues, it speeds up absorption of air). Raising blood pressure might force the bubbles through her heart before doing permanent damage. Clamping the aorta raises blood pressure as well. It's a dangerous combination of maneuvers, but as they say about desperate times...
Indeed, bubbles were moving through her coronary arteries, lined up like ticket-holders to the Stygian boatman, as frightening a thing as I’ve seen, operating. But, as hoped, they marched on through, and I began, incrementally, to release the clamp; now she was able to maintain her pressure, as she hadn't before. Without obvious signs of brain injury, she awoke later in the ICU, her cardiogram returning rapidly to normal. Sixteen stab wounds, a near-fatal cardiac emergency: not a single after-effect.
Being young, before experience ground such misconceptions away like centuries of sea on stone, I figured, having rummaged around in her entrails and having held her heart in my hand, squeezing it alive, I of all people should be able to get through to this lady, humbly receiving her gratitude while clearing the demons in her mind. Well, of course, no. Neither could the psych consultant.
[Image source]I’d taken that graphic and ill-forgotten picture thinking I might use it in a lecture or an academic paper on penetrating chest injuries, but never did. I kept taking my laundry to the same place, never mentioned the envelope, and our conversations soon found their way back to normal.