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Diagnosis Deconstructed

Diagnosis Deconstructed: Going by Feel

Morchi, Ravi MD

doi: 10.1097/01.EEM.0000425845.64733.bc

    The call. Multiple gunshot wounds to the head and chest. Nonresponsive. No pulse. Will be here in five minutes.

    I suppose our options are all dead or only mostly dead. Are there QRS complexes? No vital signs, but any sign of life? Narrow complexes reflect an intact His-Purkinje system and by inference possibly some flicker of movement in myocytes: myosin clicking away on actin. Meager LV motion that expels a trickle of blood out the aorta and up the carotids and vertebrals. A slow stream of nutrients heading to the cerebrum. A sign of life in the absence of a measurable vital sign. Provided the time interval has been short, we can act on this.

    Pointless? Even if he has a sign of life in narrow complexes, there may be no meaningful endpoint to that blood. With gunshot wounds to the head, he is likely nonresponsive from a devastating transcortical bullet wound. It would not matter much in that case if he had a sign of life or even a vital sign.

    The trauma surgery resident and our emergency medicine resident set up for a resuscitative thoracotomy, but I feel it will not be needed. A second emergency medicine resident is at the head of the bed to intubate. We go through the motions in preparation, but I expect no action to be taken here. That is my mindset going in…

    … until he arrived. Hoisted onto bed one, I notice the paramedic monitor display narrow QRS complexes. Narrow, fast complexes. Promising for flow. But what about the destination?

    Two bullet wounds in the forehead. Quite anterior actually. Is there any other wound? The emergency medicine resident at the head feels around the occiput. The hair and scalp caked in blood, it is difficult to see if he has other holes. But you feel. Feel for a bogginess indicative of a hematoma from a penetrating injury. Feel for soft brain matter oozing out.

    He feels nothing like this. So our options are just two. The patient has two entries and no exit, with tracts of injury that cross one or both cerebral hemispheres in the sagittal plane from front to back, a devastating neurologic injury that would preclude any further resuscitation despite the motion of actin on myosin below. Or there was just one shot and it scythed anteriorly through his frontal lobes. The prognosis in this case would be very different.

    It is an important question, and one I could not answer with certainty. A moment of indecision may be a moment too long in this scenario.

    I scan down his chest and see a smattering of wounds to the right of his sternum. From the neck down, he would be a candidate.

    It has been only a few minutes since his loss of vitals. But I need a second. I need more information. Ultrasound of his heart shows motion but no tamponade. His narrow, fast complexes are telling the truth.

    The residents survey his wounds and wait for word.

    “OK, go for it.” I hope this is right. I can't even tell if it feels right. But I can see my position called out in a panel of attending trauma surgeons questioning why we did a thoracotomy on a patient with multiple gunshot wounds to the head. What would I say?

    When seconds matter, indecision is a decision.

    The left anterior lateral thoracotomy reveals no blood in the pleural space and an empty pericardial sac. The myocardium is beating agonally and LV volume feels low.

    So far, no good.

    His aorta is cross-clamped with a long vascular clamp.

    A right chest tube is placed and pours out blood. I suppose at this point we need to go the distance. We have to step up. I already committed us to this regrettable path.

    Extend the anterior most part of the thoracotomy incision transversely across the sternum and then over the contralateral rib space of the right chest. Bring it down within the intercostal space all the way to the anterior axillary line on the right. With the sternum exposed, take an osteotome or a pair of trauma sheers and chop through the sternum transversely. You will have lacerated both internal mammary vessels, but their sacrifice is small here. Once you have come across, move the rib spreader to the midline where it can engage the upper and lower halves of the sternum. Then open the clamshell and use your hand to bluntly take down the loose connective tissue between the anterior pericardium and the undersurface of the sternum.

    Where are you going? In a patient with signs of life after penetrating chest trauma and blood coming from the right pleura space, you are going to the right pulmonary hilum.

    Once the right hemithorax is exposed, I see it is flooded in blood. A right tension hemothorax released?

    Blood gushes out over the gurney and onto the floor. I cannot see much. So I feel. Feel for the lowest part of the right lung. The right lower lobe. Standing on the right side, I tug it gently laterally toward me. This exposes its inferior-most connection to the mediastinum: the inferior pulmonic ligament. Lift it up and look carefully, and you can see where lower lobe ends and the ligament begins. I take a pair of Metzenbaum scissors and incise the ligament from inferior to superior, stopping just short of the inferior pulmonic vein. I cannot see it well in a pool of blood, so I feel for a rubbery horizontal tube that marks the superior extent of the ligament and the inferior extent of the hilum. And don't cut that tube.

    Now that the ligament is gone you can encircle the entire right hilum with the thumb and forefinger of your left hand. Take a vascular clamp, Satinsky, or a long straight one in your right hand and open it wide. You cannot handle the clamp via its eyes because you would not be able to open it wide enough to engage the entirety of the hilum. So instead, I handle it more proximally, near the point where the two limbs of the clamp cross. After opening, I touch one clamp tip to my index finger and one to my thumb encompassing the hilum. Then, keeping contact between the tips of my fingers and the tips of metal, I gently slide my hand out of the way to be replaced by the limbs of the clamp.

    Close it.

    Congratulations. All blood flow into and out of his right lung is now cut off. The main pulmonary artery and three pulmonary veins flattened together. All airflow is also stopped, ending the possibility of transmigration of air from the open end of an injured bronchus to the open end of a lacerated pulmonary vein. From there, transmigrated air could go into the LA, LV, aorta, and the brain. A hilar cross clamp stops blood loss and also — quite importantly — stops arterial air embolization.

    Volume transfuses into peripheral lines, and his cardiac motion picks up. He has a carotid pulse.

    The attending trauma surgeon enters and asks the question. Why did you perform a thoracotomy on a patient with GSWs to the head? His resident is taking the brunt of the attack as the attending suggests we call the code.

    Then our emergency medicine resident speaks up. He is gagging. The patient, he is responding. He is moving.

    He's in there. One point for the scything theory.

    “Do you really want to call this?” I ask my colleague. I find posing questions to our consultants, rather than making statements, puts the onus on them and tends to provide a more thoughtful response.

    He looks over the anterior cranial wounds, removes the aortic cross clamp, and given that the blood pressure is still measurable, agrees to take the patient to the OR to perform a stapled pneumonectomy.

    I believe I have created a disaster. Even if he did not have a devastating CNS bullet tract, what are the chances he would make it out of the OR or the hospital with any meaningful neurologic function? Would the surgical service curse our name every day and night they rounded on him?

    After the OR, a stat head CT would prove the scything bullet tract theory true. I curbside the neurosurgery resident called to consult on the case in the surgical ICU and ask about the prognosis for such an injury across a frontal lobe. He gives a thumbs-up.

    One month later. “Dr. Morchi, remember that patient…”

    Uh, oh.

    “…the one you did the clamshell and hilar clamp on?”

    “Uh, yes.”

    I learn he was discharged from the SICU to the floor, able to stand with some assistance, and is on his way to a rehabilitation center.

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