Monday, March 29, 2004

My partner and I spent our lunch hour operating on a 19 year old who had been running from the police and seems to have made the mistake of pointing a weapon toward them. They took offense to this and shot this individual with a .40 caliber weapon. The entry wound was at the right midaxilliary line with the projectile in the subcutaneous tissue at the midline. Off to the OR we go. After a right chest tube was placed the exploration began....
Large amount of blood found within the abdomen, most in the right upper quadrant. Performed a Pringle maneuver to control the hemorrhage. The hollow-point bullet tore a 5cm wide and 2cm deep laceration along the anterior surface of the liver. Needless to say the damage was extensive. Multiple portal and hepatic venous branches along with hepatic artery branches were injured. Titanium clips and silk suture were used. Avatine and packing were applied to the raw surface to try to gain hemostasis with little effect. Fibrin glue was applied (home-made, since the only Tisseel carried at big hospital was in the 1cc amounts. We then were faced with the unfortunate situation of the triad of hypotension, hypothermia, and coagulopathy. The decision was then made to leave the packs in and pursue a damage control laparotomy plan. Packs were left in and a 3-liter irrigation bag was cut and autoclaved. Using a modification of the Bogota bag one-half of the bag was placed over the bowel with a towel. A VAC sponge was placed over the bag and the rest of the bag was placed over the sponge. The sponge was connected to suction which helps with the "cleanliness" of the wound. The patient received multiple units of packed cells and plasma. The utility of this approach is to allow for correction of coagulopathy and hypothermia with planned return to the OR.
Apparently the police force has great confidence in us as they say that while the patient is in "critical condition" (you think?) he is expected to "recover fully". At least he has the advantage of youth.
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