Tuesday, December 04, 2007

Twice in one night

Gang wars happen often enough, and I've seen plenty of their victims, but lately these gang members, or "Family" members seem to be getting younger and younger. The other night a crew brought in one such kid, a 14 year old, whose chest made a nice home for the blade of a knife. He was scared, his face didn't lie. Mom was holding his hand as the cot turned the corner into trauma one, but shortly her grasp was broken as we began to work on her son. The 3rd year trauma resident working that night took one good look at the stab wound:
it was right chest, midclavicular, just about 3rd intercostal; he then pushed his gloved index finger into the wound and it came back bloody up to the second joint. "Chest tube set up on this side please." He hadn't even listened to breath sounds, but just by watching this kid's work of breathing and seeing that stab wound, he knew a thoracostomy was the path of action to take.

Not only was this kid stabbed on the streets, but now he's hearing the doctor tell him that he has to stab him again with about a half inch wide tube that will go into his side because his pleural cavity is filling up with blood and his lung can't expand as it should. There's a paramedic student, wide eyed, and ready to help, I tell her to stand at the head of the bed and hold this kids little arm above his head so his chest is an open canvas for the doc. And literally, it is a canvas: the rust orange betadine is the paint, swirled around in bigger and bigger cricles until the entire right side of the chest is prepped.

This kid is tachypneic and he is so diaphoretic it's as if the ambulance stopped by at the local pool on the way here. I can hear the doctor giving pointers to the med student as he begins the procedure, "You wanna find the intercostal space between about ribs 5 and 6, midaxillary," he's feeling this kids ribs, there's the spot, "then grab a #10 and make about a 3cm or so cut like that," As he says this he takes the green scalpel and slices, the light brown skin separates, revealing the red flesh beneath. "Then, use one of these curved hemostats.." He riffles through the plethora of tools there on the tray and mumbles a few words under his breath, then, upon locating his tool, he jabs it into the incision, "You gotta shove it through this muscle right here," a grimace on his face, using a little of his own muscle, he's twisting the hemostat, employing his whole arm, elbow up, then down, as if he's changing the lugnuts of a tire. Then he reaches for the 32 French tube, and using the hemostat now clamped to the end of the tube, he advances the giant staw into the pleural cavity. Usually the tube fogs once it's in place, that's how you know you're in, but this time the fog was hidden by the rush of blood that flooded the tube; he had a hemopneumo. "Now you just have to sew it in place, where's the 0-silk?" After a few adept sutures and dressing, this kid is good to go.

He's breathing easier now. "Let's have xray shoot a chest before we go to the scanner." After the thoracostomy was successfully done, and only about 200cc of blood out in the Pleur-Evac, this kid went upstairs and is recovering as I write this. Pretty soon he'll be back out on the streets, worrying his mother, playing with knives. He'll live another day, probably several, and wishful thinking hopes that he will change his ways and start feeding the poor. I just hope I don't see him again flat on his back, arm above his head.


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