Whar's the Bullit?

First the xrays, as usual. More later. No peeking by clicking on the xray. I'm too lazy to change the name of the file. It's one of those rare cases that ya don't see every day.

---------------------------------------------

"Hey, this ain't bad at all!" I commented as soon as I stepped into the ED to start my shift and noticed that the census board was rather "clean."

Marsha, a veteran ED charge nurse with over 30 years of experience hesitated not a bit in giving me a quick bop to the back of my head like my older brothers used to do. "Why'd you say summin' like that for?!!" she protested in a displeased but not too incensed tone of voice. "You done jinxed us all!"

"Hey, er..." I started stammering and rubbing the back of my head after realizing that I had violated one of the cardinal rule of the ED. "I didn't specifically refer to nothing," I argued back unconvincingly. "I was just saying things in general, you know, like life ain't bad at all. That kinda thing. It's a generic reference."

"Yeah, but we know what you meant. You done said it. You done jinxed us!"

"Man, you guys are too superstitious. That kinda thing has never worked for me anyway. I've always been the shit magnet, the black cloud, I get dumped on regardless of whether I say the word quiet or not. So there! I said it. QUIET. NOT BUSY. QUIET! QUIET! QUIET!"

"Oh God! He said the Q word. Hey everybody, Dr.___ just said the Q word!"

"Gee, thanks, Dr._____. You done jinxed us!" they groaned.

I shook my head and replied, "What-ever! I don't believe in that whole jinxing crap anyway. If that's the case, then I'm perpetually cursed because I can't even remember the last time we had an easy night here. I can't even remember the last time I was able to sit on my ass and finish a crossword puzzle or surf the internet like in the old days when I first started here. I can't even remember the last time I was able to take a short nap. Shit, on many nights, we get so busy, I even forget to go take a piss, much less eat something. It's like as soon as I show up, the ER gods said let the activated charcoal run and we get dumped on."

Just as soon as I ended that li'l whiny rant about placing patient care above even emptying our own bladders, Billy, one of the new nurses who got suckered into transferring from the SICU to work in the ED, came up to me and informed, "Hey, they need you on the radio. It's AirMed 1.

"Alright, here we go! Told y'all, he done jinxed us!"

"AirMed 1, this is CCMC med control, go 'head."

"Hey doc! AirMed 1. ETA to you in 20 minutes from Podunc County. 23 y/o male, GSW to the left flank. He's in hypovolemic shock. BP 70/palp. Sinus tachy at 150, O2 sat can't pick up but breath sounds are equal bilaterally. He's awake but diaphoretic and lethargic. 2 large bore IV's with fluids wide open on pressure bags. We're loadin' him up right now. Permission for RSI..."

"That's an affirmative! Etomidate and Sux per protocol. Go 'head and secure the airway. Make sure you check for end-tidal CO2. Pavulon as needed. Update us of any changes. CCMC out."

"Notify the OR, please," I went into Defcon mode. "Get Dr. Slasher on the phone. I want 4 units of O neg blood here now. Warm up the Level I infuser. Chest tube set up, suction..."

"See there, damn it, you done jinxed us!!! I can't believe you said that!"

We met the patient at the helipad. He didn't look spiffy at all, had that CD square look about him (circling drain, waiting for celestial discharge).

"4th and 5th bag of saline hanging, doc. Last BP 90 systolic, still tachy. His uncle shot him while climbing out of the bedroom window! S.O. (Sheriff Office) said that he'd been 'messin' with his ucle's wife!"

"Yup! That would explain Podunc's gene pool!" I couldn't contain the chuckling after hearing that comment from Marsha.

We rushed the patient into the trauma bay and proceeded to violate every orifice with our prying fingers and invasive tubes, while going rapidly through the primary and secondary survey of ATLS. Massive volume resuscitation was delivered with uncrossed match blood along with IVF pumped in by the Level I infuser at full speed.

"We're just waiting on The Slasher," said the OR crew hovering around waiting for the go 'head word to whiz the guy up to the OR.

Single GSW with entrance wound to the left flank, no exit, was all the injury that the guy had on full body exposure and log-rolling.

"Got your chest xray and KUB up!" announced the xray tech.

"Whar's the bullit?!" I kept on asking out loud after seeing both unremarkable xrays. "Whar's the bullet, whar's the bullet...No exit wound...Whar's the bullet?"

"Let's go lower," I then instructed the xray tech. How 'bout...."

"He's bradying down!" yelled Billy.

It was then that the answer became very clear. The guy's right leg and foot suddenly turned ominously purple and pulseless. Only the 2nd time in my career have I ever seen such a case. Here are some more views with the lateral:





Holy Shit! Single GSW to the left flank, no exit. How the hell did the bullet end up in his leg? There were no wounds in his leg.

A bullet embolus! The bullet penetrated the aorta and embolized to the popliteal artery of the leg causing a complete occlusion at the trifurcation.




"He's in V-fib!" yelled Billy again.

We shocked him into an idioventricular rhythm and gave a few rounds of Epi achieving a return to a sinus tachycardia. The rhythm then quickly degenerated again to a pulseless wide complex bradycardia.

"Let's cross-clamp the aorta and stop that bleeding. Set me up a thoracotomy tray!!"

--------------------------------------------

It was all anticlimatic from there, I'm afraid. Wide-complex bradycardia is an ominous sign in trauma resuscitation. My hope was to get his heart back to ROSC (pronounced rosky for Return of Spontaneous Circulation) with a pulse. And since he's young, hopefully would have a better fighting chance in the OR. I haphazzardly squirted betadine onto the left chest and threw some sterile towels onto the stretcher. Breached the parietal pleura with one firm, swift slash of the scalpel. Smooth, like cutting butter. After cranking the rib spreader, I dug my hands into the posterior thorax. All of the injuries seemed to be below the diaphragm as there was no blood at all in the chest. After locating the descending aorta, I quickly cross-clamped it. Just then, in come Dr. Slasher, young general surgeon extraordinaire.

"Looks like y'all started the party without me."

"Single GSW to the left flank, no exit. Look at where the bullet is on the xray," I pointed out and reported to The Slasher.

"Holy Embolism, Batman!"

Slasher snapped on sterile gloves and gave cardiac massage. I loaded up the needle and gave an amp of intracardiac epi. ROSC!

They whizzed him up to the OR, but his injuries were too extensive. Got the bowels, got the left kidney and penetrated the aorta just infrarenally. He made it out of the OR but died in the SICU a few hours later. Sad part of it all was that no family member or friends ever came to ask about him. I'm not a believer in getting jinxed or anything, but the night was just pure pandemonium and busy as hell afterward.