When there is just too much trauma!

The hospital in which I currently work is unfortunately not a Major Trauma Centre, although the head of Emergency General Surgery tells me that the Big Wigs have aspirations to make it one in the next 10 years - so long as Neurosurgeons can be persuaded to work here. Nonetheless, in a typical on-call week you can currently only be expected to be dragged down to A&E once or twice for a trauma call and consequently trauma laparotomies are vanishingly rare! Last weekend however, my Sunday afternoon got a bit exciting!

The Consultant was being supportive and hanging around unscrubbed in theatre whilst I attempted a somewhat troublesome Hartmann's for perforated diverticular disease that had been brewing on the ward for a little while before deteriorating that morning. As I was firing the Contour stapler to divide the rectum, the trauma bleep went off, so we sent the SHO off to investigate and the Consultant scrubbed in to help me. Not long afterwards, the SHO called back to excitedly report that the patient in Resus had been "EVISCERATED"! The Consultant abruptly took over from me and finished the Hartmann's in double quick time. By the time I was closing the skin the SHO, to his credit, was in the lift on his way to theatre with the patient.

Moving next door, I found the patient already on the operating table. She had been involved in an RTA; her car having been hit from the side and flipped by a large truck. Although there was not the protruding bowel that I had envisaged from the SHO's excitable description, her abdomen was distended, with an obvious 'seatbelt sign' distribution of purple bruising. The anaesthetist was worried that she was a little unstable, and I could see a unit of packed red cells going in. I therefore got on with a midline laparotomy. 

Going through the subcutaneous tissues, my access to the linea alba was impeded briefly by a large haematoma in the subcutaneous tissues of the lower abdomen that had stripped the fat off of the abdominal wall and was sitting in that seatbelt position visible externally. Entering the peritoneal cavity, there was the classic 'ppffss' of pneumoperitoneum, before a rush of dark blood mixed with small bowel content. We packed all four quadrants with large abdominal packs to mop up the mess and hopefully tamponade any source of bleeding. Unfortunately, when systematically removing the packs, there was clearly still both blood and poo spilling out quite briskly from somewhere! Luckily it didn't take too long to identify - there were several long ragged tears to the small bowel mesentery that were spurting blood. These were controlled easily enough, initially between thumb and forefinger and then with a Vicryl stitch. The small bowel content was spilling from a complete transection of the mid ileum, the two ends of which were flapping about messily! I quickly controlled this by stapling off the severed ends with a GIA linear cutting stapler.

At this point, if you can believe such a thing in our non-major trauma centre hospital, things got even more hectic! Another trauma patient crashed into the theatre next door, apparently with the A&E Consultant being wheeled along on the trolley with the patient, still doing chest compressions. My Consultant tore off his gloves and gown and went to investigate. I continued with haemostasis of the ruined small bowel mesentery, until a short while later my consultant reappeared briefly at the door of theatre, this time with his hands, arms and scrubs absolutely drenched in blood! "You are going to have to cope" he shouted wildly before disappearing again! What on earth was going on next door!?! Here I was, flying solo on a trauma laparotomy, and feeling distinctly jealous that I was missing out on whatever the hell was happening in another theatre!

I continued exploring and washing out the abdomen and convinced myself that both the liver and spleen appeared to have survived the trauma without injury. Around 180cm of small bowel was completely dead, so I resected that. The rest of the viscera thankfully appeared to be intact. There was however, one rather tricky injury that I was at a loss at how to deal with. The seat belt appeared to have ripped the abdominal wall muscles off of their insertion on the right iliac crest, leaving a gaping hole in the posterior-lateral abdominal wall. I pondered what on earth I was going to do about this. A few attempts at bringing the edges of the defect together with sutures immediately failed, as one edge was the hard bone of the iliac crest, and the other was macerated abdominal wall muscles with the soft consistency of a raw hamburger. After a bit of messing about, I eventually tacked a vicryl mesh over the hole in an intra-peritoneal position, which felt rather unsatisfactory, but was the best I could do to keep the abdominal contents roughly within the peritoneal cavity without spending too long with the patient on the table. As the anaesthetist was feeling much happier about the patient's overall condition, I then performed a side-to -side stapled small bowel anastomosis and closed the abdomen.

In the theatre next door, there was now a rather sober atmosphere. On the table was a very young man who had been stabbed several times in the chest and abdomen. He had undergone a clamshell thoracotomy and laparotomy and been re-filled with blood products. Sadly, despite this he never regained cardiac output and the team had eventually been obliged to stop. The A&E Consultant was sat in the coffee room with a couple of police looking utterly devastated. My Consultant and the Thoracics Consultant said they had done all that was possible in a very quick timeframe, but the young man had lost cardiac output some time before he arrived at hospital, and the outcome for such cases is known to be very poor. Suddenly I was glad that I had been protected from this tragedy of wasted young life, and just hoped that my patient would not suffer from my lack of experience in what otherwise would very much have been a consultant-led case.

Does anyone have any advice for how to deal with a clinical situation in which they have little experience when your boss is tied up with another case? How do people approach traumatic abdominal wall hernia? Is there anything I could have done differently?