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Mon Sep 27 01:03:00 BST 2010

I will continue with the next steps when I know that this case has been  
read and known to this list serve membership

In a message dated 9/20/2010 12:51:24 P.M. Central Daylight Time,  
KMATTOX at aol.com writes:

____________________________________
 From: KMATTOX at aol.com
To: trauma-list at trauma.org
Sent: 9/18/2010  11:36:54 A.M. Central Daylight Time
Subj: Week End Case Phases 1, 2,  & 3

In that Trauma Org has been down a few days, I am going to repeat the  
first 3 phases of this case and catch you up to date before we go on with  the 
case and those many persons who have already given me differing bits of  
advice as to what is going on and what we should do next.  

PHASE 1

After unknown reasons for a shooting, an unknown named 30ish man was  
brought to the shock room with pulse of 120, variable BP depending on who  was 
taking it with what automatic recycling machine, but most around 90/-  had a 
bunch of holes in him:     I am embellishing the  case a bit to make it more 
interesting to this group and I will tell you the  next step after I get a 
number of suggestions for treatment or  process.     

- two holes around the buttocks posteriorilly.   Rectal  shows NO BLOOD on 
glove and sphincter tone is good

-One large bleeding hole with accompanying a big apparently  abdominal wall 
appearing hematoma in the left lower quadrant to the  left of the midline 
and above the inguinal ligament, clearly NOT below  the inguinal ligament

-One bullet hole in  right mid thigh near Hunters canal

-One bullet hole in left distal thigh, near Hunters canal

There may have been one or two other bullet wounds, but believe me they  
are not necessary to this case as I am presenting it.   

As I get to the hall outside the shock room, where the patient is being  
evaluated I find total chaos with the emergency room and its seemingly  
hundreds of physicians, nurses, students, residents,  etc.     

The hospital is already on driveby because of lack of telemetry beds,  ICU 
beds and far too many medicine admissions and a 20% observation and  short 
stay admission rate.    The EC is at 150% occupancy and  all of the shock 
rooms have monitored patients in them awaiting ICU or  telemetry bed.    

A chest X-ray and abdomnal X-ray  had been taken by an  avalable machine, 
and there was no chest pathology seen, and the abdomen  looked ok, except the 
marker of the site of entry on the abdomen and  buttocks.    NO Missiles 
were seen  anywhere.     

As I arrived, a 45 caliber bullet fell onto the floor from out of his  
cloths covering his lower body.and legs.   

He had equally weak pulses in three extremities, but NO PULSES in left  
groin, left popliteal, and left foot.

Unable to get a Foley catheter in and no urine has been  produced.  

One of the persons in the ED had drawn a bunch of blood tubes and  was 
asking whoever would answer as to what tests they  wanted.       I will tell you 
that one of  the tests was a blood typing which later came back A  
negative.     What tests your YOU order, or allowed to  be done.  

He had not gotten but about 60 ml of Lactated Ringers crystalloid  fluids 
in the ambulance and ED   

In the confusion, I was being told 3 different things as what to do,  
depending on rank and specialty of the persons speaking.   The  options of the 
more senior persons included:     CTA of  abdomen to plan operative 
approaches.    Arteriogram.       Laparotomy.     To IR for stent  placement.      Cut 
the  groin.     Explore the popliteal  artery.      Call the vascular 
surgery  service.      Do a FAST of the  abdomen.      Do a CT of the abdomen, 
pelvis and L  leg.    

You now have all the information I had at the time, except, there is an  IR 
suite, a CT suite, and an OR open at this  time.      

WHAT TO DO??

[We got a lot of conflicting advice, but most persons said, "go to the  OR"]

PHASE 2 POST ON WEEKEND TRAUMA CASE

NO CT ,  NO CTA in the EC.   No  arteriogram.     No IR,   Went straight to 
 OR.    Foley catheter inserted without  difficulty.   NO blood in urine

As suggested by several discussers, we were planning a  laparotomy.     
Prep from chin to  toes.     Both legs prepped out.      The proceeded with 
LOWER MIDLINE LAPAROTOMY.  On entering abdomen-  Almost totally normal anatomy. 
   NO BLOOD in  abdomen.    Way laterally and anteriorilly there was a  
hematoma, consistent with the hematoma previously described in the PHASE I  .   
 Rectosigmoid totally clean.    No extra  rectal tissue blood staining at 
all.   NO HOLES in the peritoneum  anywhere.     

The faculty then went to the outside of the abdomen to look at  the big 
hole in the left lower abdomen over the lower rectus  sheath.   He put his big 
thumb in the hole and probed, as possibly  suggested by one of the earlier 
posts.    When he pulled  the thumb out, BRIGHT RED BLOOD came rushing out, 
BIG  TIME.     Looking at the hematoma it definite is ABOVE  the inguinal 
ligament.      There is NO pulse in  the left groin.     There was a great 
pulse in the  left common and external iliac arteries in the  abdomen.    

NOW WHAT SHOULD WE DO??

[LOTS of advice, but most persons wanted us to do some sort of imaging  in 
the operating room, like an arteriogram]

PHASE 3 (and Trauma org went off the air for a week just as  this was sent)

Just so everyone knows where we are on this case and there is no  
confusion.  

30 YOM with several GSW to body; 2 to buttocks, one L medial  distal thigh, 
one lateral r distal thigh, and one in abdominal wall over  lower rectus.  
No pulse in left groin or left foot.    Hematoma above inguinal ligament on 
left towards the rectus.  Abdomen  has been OPENED and NO injury 
intraperitoneally,   NONE.        Good pulse in both iliac  arteries.   Left external 
iliac artery has been looped with  umbilical tape (NOT a vessel loop).    
Profuse bleeding from  anterior abdominal wall was controlled by 6 inch 
incision over the GSW hole  over the lower left rectus and 2 figure of 8 sutures 
controlled the bleeding  from the two ends of a very vigorously bleeding 
inferior epigastric  artery.  (by the way, off of what major artery does the 
inferior  epigastric artery begin).    The inferior epigastric artery  bleeding 
was very near the supra inguinal ligament hematoma.   NO  active bleeding 
seen now.   We are 4.5 minutes into the  operation.     Still no pulse at left 
groin or left  foot, and GOOD external iliac pulse as felt inside the  
abdomen.    .      

NOW what should we  do?

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Week End Case Phases 1, 2, & 3