There is a 30-something Australian radiology technical consultant working for MSF here. He is getting the x-ray department in order including training the radiology technicians and setting up the hardware and the software. The other day we looked at an x-ray together of a man who had been shot in the chest two months earlier. It wasn’t clear why someone had ordered the chest x-ray as the man was now completely asymptomatic but the bullet, big enough that it came from something akin to an AK-47, was still in his chest.
With two pictures at 90 degrees from each other, front and side profile, you could see that the bullet had ended up sitting adjacent to the superior vena cava, the main vein that brings all your blood back from your head and arms to the heart. If the bullet had travelled one inch further toward his left, the man would have died within minutes. Looking at the digital image on the x-ray screen, my Australian colleague said “He’s a lucky bloke”.
The other day I was called to the ER to see a different man with a different gunshot wound. He had a medium size hole just under his right collar bone big enough for me to put 4 fingers in it and compress his subclavian artery, plus a bigger hole in his armpit. The ER doc had seen blood in the chest using bedside ultrasound and was just putting in a chest tube when the anesthetist Dr. K. and I arrived. Half a liter of blood poured out of the chest tube in the first 10 minutes and by the time we were up in the OR (about another 15 minutes) he had put out just around 1000 cc in total, the majority of which was being transfused back to him. Usually if a patient puts a liter of blood out of his chest that soon after a gunshot wound, he will need an open chest operation called a thoracotomy to stop the bleeding.
Somewhat surprisingly our patient’s blood pressure was still in the normal range, his pulse was decreasing, he didn’t have other signs of shock and most importantly the bleeding from his chest tube had slowed dramatically, so rather than opening his chest we began by exploring the wounds he already had. I made incisions extending the wounds to examine the blood vessels from the collarbone to the biceps area of his arm. There were no injuries to the major artery or vein, just a few branches that were torn that needed sutures plus bleeding from shredded muscle. Interestingly enough we couldn’t find an entry wound into the chest.
It looked like the bullet had entered under the collarbone, missed all the major structures, bounced along the chest wall and blew out the skin under his arm. The internal chest bleeding had probably been due to smaller vessels that were torn but had now stopped bleeding, rather than a major vascular injury. I placed a second chest tube, directing it down toward the lower chest, to be sure that we weren’t missing some significant bleeding but the bleeding inside the chest had virtually stopped. Thinking out loud, I said that without ongoing bleeding or a big air leak from the lung, there was no reason he needed a thoracotomy so we would just sit tight and watch him for a few minutes and see if the chest tube output remained low. My anesthetist K. said “Well, he’s lucky.”
We all know that if our patients were truly lucky they wouldn’t be our patients at all. But it is difficult not to think about who is lucky and who isn’t. I have two patients who we evacuated from Carnot with similar gunshot wounds to the lower leg and open fractures of the tibia. Both have external fixators in place to stabilize the bone for healing. The lucky one is in his 30’s because we could get his bone covered with muscle using what is called a soleus flap (more specifically a reverse hemi-soleus flap). He will get a skin graft over the flap later this week and have his wounds completely closed. The unlucky one is 19. His fracture wasn’t as bad but he lost most of the muscles and tendon behind the bone to the blast injury. With most of the gastroc and soleus muscle gone, his dressing changes are bigger and more painful plus there is a significant chance he may not heal the wound and need an amputation.
Good fortune is all relative and nowhere more so than on a trauma service. As a surgeon, I believe you make much of your own luck by being careful in making a diagnosis, paying attention to details in the OR while still moving quickly and efficiently and watching carefully for post-operative problems that are better addressed early than late.
As a person, I’m a bit more fatalistic. I know have already enjoyed more than my fair share of random good fortune in life. My luck is as likely to go south in Seattle on a rainy, slippery freeway during rush hour as in Bangui or Carnot with MSF. But even the best surgeon has complications with missed injuries or unexpected post-operative bleeding or the severely injured patient that just doesn’t make it. And even the most careful person can find themselves in the wrong place at the wrong time.
Today I am feeling very grateful for my good luck and consider myself the second luckiest man in all of Bangui today. Why number two? It seems like I would be tempting fate to claim the number one spot. Knock on wood.