F
Field Ethos
Guest
By Will Dabbs, MD
I work in an urgent care clinic. I have served my time in an inner city ER. That was every bit as stimulating as the TV shows make it out to be. However, I couldn’t see my doing violent dismemberments, catastrophic strokes, and gunshot wounds for the next 20 years and emerging with my head right.
I do cut and sew all the time. That’s actually fun. However, nobody is supposed to die in my clinic. And then there was this one lunatic guy…
I met this dude and his unwashed buddy in Room 7—the treatment room. Room 7 is the playroom—my favorite place at work. A nice chainsaw to the thigh is way more diverting than diabetes or hemorrhoids.
Our hero was a construction worker. He was young and jacked with a bloody t-shirt wrapped around his right arm. I peeled the edge back far enough to visualize a roughly 1-inch longitudinal laceration in the antecubital fossa—the inside of his elbow. It was oozing a bit but nothing about which to alert the media.
He explained that he had snipped the steel strap off of a big cube of bricks. The razor-sharp edge had recoiled back and popped him in the arm. He bound everything up with a t-shirt and came to see me.
Without much fanfare, the patient then produced a pocket knife and cut the t-shirt loose. That’s when I saw the tourniquet they had fabricated out of a bootlace around his bicep. Before I could stop him, he then inexplicably cut that as well. Blood poured out of that guy’s arm like it was coming out of a garden hose.
It was immediately obvious what had happened. The blood was voluminous, but it wasn’t pulsatile. The brick strap had apparently lacerated the median cubital vein lengthwise—the large-bore piece of plumbing that phlebotomists use to draw blood. As I rushed over to get the lay of the land, his grubby buddy offered a little unsolicited insight.
Apparently this gentleman had already been bleeding quite a lot and for a long time. His pal said the job site looked like a slaughter house. He also claimed there was blood standing in the floorboard of his truck. That’s when the lacerated man lost consciousness.
Blood is opaque—you can’t see through it. I mopped it clear with some 4×4 gauze, but that didn’t help much. There was more coming out than I could manage in a timely fashion. I grabbed a box of rubber gloves and improvised a tourniquet, tying it tight around his upper arm. That helped a little bit but not much.
This guy was really ripped, and getting enough pressure down to those deep arteries was a challenge given the tools at hand. As it was a vein that had been ventilated, the blood was technically coming back from his fingers, not directly from his heart. Another improvised tourniquet around his forearm slowed things down just enough to work.
It’s weird what you think about under those circumstances. The big hospital is five minutes up the road, but there’s no way this dude was going to live to see it if I couldn’t get the bleeding stopped. If a guy arrests as a result of exsanguination, is CPR really going to help? I’ve coded my share of folks, but I can’t say I’d ever pondered that specific scenario. If this otherwise fit 25-year-old actually dies, who do I call? If he’s inert and cooling when they arrive, the ambulance crew is likely not going to be feeling it. All that runs through your mind when you’re trying to get ahead of a really bad situation.
I got my nurse to start squeezing the crap out of the guy’s arm. I then grabbed a needle driver and some 3-0 Vicryl suture, the first I came to, and threw a couple of deep stitches up and downstream. I didn’t have time to numb it up or do much in the way of sterile prep. However, the patient was out. He didn’t much care.
Once I got things tidied up enough to see what I was doing, I threw a figure of eight over the vein and then closed the skin. Thank the Good Lord I didn’t inadvertently ligate the guy’s median nerve or brachial artery. He sort-of regained consciousness a short while afterwards. Two bottles of Gatorade later, he could walk, albeit in a somewhat wobbly fashion.
I saw him eight days later to get his stitches out. The wound looked great. He said he was doing fine though perhaps a bit lightheaded. I didn’t bother asking him if he realized how close he had come to meeting Jesus in Room 7 at the Urgent Care Clinic of Oxford, Mississippi. Incidentally, if you find yourself in Room 7 at some point, you’ll note the RATS tourniquet hanging on the wall. That’s just because of one particular lacerated man.
The post The Lacerated Man appeared first on Field Ethos.
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I work in an urgent care clinic. I have served my time in an inner city ER. That was every bit as stimulating as the TV shows make it out to be. However, I couldn’t see my doing violent dismemberments, catastrophic strokes, and gunshot wounds for the next 20 years and emerging with my head right.
I do cut and sew all the time. That’s actually fun. However, nobody is supposed to die in my clinic. And then there was this one lunatic guy…
The Subject
I met this dude and his unwashed buddy in Room 7—the treatment room. Room 7 is the playroom—my favorite place at work. A nice chainsaw to the thigh is way more diverting than diabetes or hemorrhoids.
Our hero was a construction worker. He was young and jacked with a bloody t-shirt wrapped around his right arm. I peeled the edge back far enough to visualize a roughly 1-inch longitudinal laceration in the antecubital fossa—the inside of his elbow. It was oozing a bit but nothing about which to alert the media.
He explained that he had snipped the steel strap off of a big cube of bricks. The razor-sharp edge had recoiled back and popped him in the arm. He bound everything up with a t-shirt and came to see me.
Things Go Pear-Shaped
Without much fanfare, the patient then produced a pocket knife and cut the t-shirt loose. That’s when I saw the tourniquet they had fabricated out of a bootlace around his bicep. Before I could stop him, he then inexplicably cut that as well. Blood poured out of that guy’s arm like it was coming out of a garden hose.
It was immediately obvious what had happened. The blood was voluminous, but it wasn’t pulsatile. The brick strap had apparently lacerated the median cubital vein lengthwise—the large-bore piece of plumbing that phlebotomists use to draw blood. As I rushed over to get the lay of the land, his grubby buddy offered a little unsolicited insight.
Apparently this gentleman had already been bleeding quite a lot and for a long time. His pal said the job site looked like a slaughter house. He also claimed there was blood standing in the floorboard of his truck. That’s when the lacerated man lost consciousness.
The Problem
Blood is opaque—you can’t see through it. I mopped it clear with some 4×4 gauze, but that didn’t help much. There was more coming out than I could manage in a timely fashion. I grabbed a box of rubber gloves and improvised a tourniquet, tying it tight around his upper arm. That helped a little bit but not much.
This guy was really ripped, and getting enough pressure down to those deep arteries was a challenge given the tools at hand. As it was a vein that had been ventilated, the blood was technically coming back from his fingers, not directly from his heart. Another improvised tourniquet around his forearm slowed things down just enough to work.
It’s weird what you think about under those circumstances. The big hospital is five minutes up the road, but there’s no way this dude was going to live to see it if I couldn’t get the bleeding stopped. If a guy arrests as a result of exsanguination, is CPR really going to help? I’ve coded my share of folks, but I can’t say I’d ever pondered that specific scenario. If this otherwise fit 25-year-old actually dies, who do I call? If he’s inert and cooling when they arrive, the ambulance crew is likely not going to be feeling it. All that runs through your mind when you’re trying to get ahead of a really bad situation.
The Solution
I got my nurse to start squeezing the crap out of the guy’s arm. I then grabbed a needle driver and some 3-0 Vicryl suture, the first I came to, and threw a couple of deep stitches up and downstream. I didn’t have time to numb it up or do much in the way of sterile prep. However, the patient was out. He didn’t much care.
Once I got things tidied up enough to see what I was doing, I threw a figure of eight over the vein and then closed the skin. Thank the Good Lord I didn’t inadvertently ligate the guy’s median nerve or brachial artery. He sort-of regained consciousness a short while afterwards. Two bottles of Gatorade later, he could walk, albeit in a somewhat wobbly fashion.
I saw him eight days later to get his stitches out. The wound looked great. He said he was doing fine though perhaps a bit lightheaded. I didn’t bother asking him if he realized how close he had come to meeting Jesus in Room 7 at the Urgent Care Clinic of Oxford, Mississippi. Incidentally, if you find yourself in Room 7 at some point, you’ll note the RATS tourniquet hanging on the wall. That’s just because of one particular lacerated man.
The post The Lacerated Man appeared first on Field Ethos.
Continue reading...
