Invisible Injuries

By Elisabeth Rosenthal|Sunday, May 01, 1994
EMS notification on 11.

These words, blaring over the emergency room loudspeaker, instantly transform a lazy Sunday morning in the New York City hospital where I work. We put down our newspapers, grab a last bite of bagel, and crowd around the nurse who is answering the call from the ambulance crew. They are on the street, tending to a critically ill patient in the freezing rain.

Forty-one-year-old male.

Pedestrian, struck by bus.

A little bit out of it, but no loss of consciousness.

Pulse 120.

Blood pressure 130/95.

Difficulty breathing.

The nurse calls out the details of the paramedics’ report as she jots them on a pad. They’ll be here in three minutes, she announces.

At once, adrenaline and ER bravado are flowing. A handful of doctors and nurses move to the major trauma bay to double-check that everything is there: intravenous fluids, respirators, an X-ray machine ready to film. In the age of AIDS, we all don yellow gowns and latex gloves since we know this may well be a bloody affair. We joke nervously, not knowing what the next minutes may bring.

You know how the paramedics love drama. I bet the bus just nicked his knee, says one surgeon.

Maybe he was drunk and he walked into the bus, says another.

It’s probably nothing if he’s awake and talking, a nurse chimes in.

We have almost convinced ourselves when the ambulance lights flash through the emergency room’s frosted-glass windows. A stretcher carrying a man screaming in agony is whisked in the door. Uh-oh. The real thing.

Although the patient, Mr. Henry, is strapped down on a wooden board with his neck bound in a stiff plastic collar to protect his spine, his pain and fear seem to levitate him off the table. Help me! I’m dying! he screams. I hate it when patients tell me that. All too often they are right.

The nurses quickly insert huge intravenous lines to prop up his blood pressure, and begin to cut off his clothes. Looks like he’s homeless, a nurse remarks to no one in particular as she deftly snips off layer after layer of shirts, pants, and socks.

As one surgeon tries to calm the man and get a sense of exactly what happened, another doctor and I scan Mr. Henry’s naked body for signs of trauma--cuts, bruises, abrasions. We find nothing. I hate blunt trauma, my colleague sighs. In emergency rooms it is a common refrain.

People tend to imagine that stabbings and bullet wounds are the most gripping of emergency room dramas, but for trauma surgeons these injuries are relatively straightforward affairs. Knives and guns leave clear tracks on the body to guide doctors; it is easy to find entrance wounds and, with bullets, exit wounds too.

But what of the body that has been hit by a bus or has fallen several stories? We know there may well be something terribly wrong inside. Fractured ribs? Punctured lungs? A ruptured spleen? A broken pelvis? Often the surface of the body offers no clue. Sometimes, as in the case of Mr. Henry--who was struck by a bus going 20 miles an hour--there is not even a drop of blood.

To avoid overlooking a vital injury, trauma surgeons approach such patients with strict protocols. It would be all too human to focus on a lacerated scalp--a gory but basically insignificant injury--and miss a fractured thighbone that had invisibly severed a major artery. Left untreated, a patient with such an injury could bleed to death.

So the trauma team focuses first on the basics: Can he breathe? Without enough oxygen every other effort will fail. Are his heart and circulatory system intact? If his heart can’t pump or a major blood vessel is torn, death will certainly prevail.

Although Mr. Henry was confused and moaning, he kept repeating, I can’t breathe. I can’t breathe. He looked like a man struggling for air: his chest was heaving up and down at twice the normal rate. When I placed my stethoscope on the left side of his chest I was relieved to hear clear breathing. But my calm turned to panic as I listened--and listened again--over the right side of his chest. No air movement. A little gurgling. No working lung there.

His right lung had clearly collapsed. Shattered ribs had probably punctured the diaphanous lung sacs, causing them to deflate. Or perhaps the rib fractures had caused so much bleeding in the chest that blood was compressing the lung.

No breath sounds on the right, I yelled to the trauma chief, who quickly ordered one of the junior surgeons to insert a suction tube into the chest cavity to draw out fluids and try to reexpand the lung. Mr. Henry hardly noticed as the doctor sliced through his unanesthetized skin, tunneled through the muscles between his ribs, and jammed a large plastic tube into the chest underneath. Immediately blood gushed out through the tube, collecting in a clear plastic box on the floor: 100 cc, 200 cc, 400 cc. It seemed not to stop.

Mr. Henry’s vital signs were even more troubling. When he arrived, his blood pressure was normal, even a little high, which gave the optimists in the emergency room some cause for hope. But his pulse was racing at nearly twice the normal rate, often a sign of significant blood loss. The optimists chalked it up to pain.

In the Emergency room every trauma patient gets fluid--lots of it--intravenously. The assumption is that the patient is probably bleeding somewhere, and the extra fluid keeps the blood vessels from collapsing and depriving vital organs of blood and oxygen. As the fluid poured in, I was relieved to see that Mr. Henry’s pressure held steady and that the chest tube seemed to ease his breathing a bit, giving the trauma team more precious time for detective work and tests. Within another minute or two, the X-ray technician had snapped pictures of Mr. Henry’s neck, chest, and pelvis. A small sample of his blood was in the blood bank being matched for transfusions. The surgeons moved down his body to complete the exam.

Miraculously, Mr. Henry’s heart and large bones all seemed fine. His cardiogram was completely normal. And when the surgeons tried to rock his hips, his pelvis seemed stable, suggesting no breaks there. This was a great relief because pelvic fractures can easily damage large blood vessels deep within the body, where major bleeding is hard to control. A nurse checked the urine and stool specimens; neither showed traces of blood. So his kidneys, bladder, and lower intestine were also probably fine.

Although Mr. Henry was foggy and lethargic, he showed no signs of head trauma, and all his major neurological pathways appeared to work. His pupils reacted normally to light. He seemed to be able to follow commands. Despite the pain in his chest, he was clearly able to move his limbs just fine: it had taken two nurses to hold each arm and leg as the surgeons completed their work.

That his brain was okay was no small blessing: you have to be lucky to keep your head off the fender or the ground when you’re mowed down by a bus. All too often trauma doctors struggle to save a battered body only to find the head that directs it is damaged beyond repair. But we knew that if we could stop Mr. Henry’s hemorrhage and repair his injuries, he should walk out of the hospital physically none the worse for his near- fatal injury.

Yet that was still a pretty big if, because we still didn’t know what was going on in his belly. If blunt trauma is the bane of the trauma surgeon, the upper abdomen--filled with vulnerable, blood-filled organs--is the reason. When intact, the framework of the ribs protects the liver, stomach, and spleen. But when these bones break, they can become razors that slash the organs below.

When a patient is wide awake, deciding if this has happened is easy. It hurts to have your spleen burst or to have blood pouring into your abdominal cavity--and patients tell you so loud and clear. But could we trust Mr. Henry?

Mr. Henry, Mr. Henry, listen to me--does your stomach hurt? we screamed through his fog half a dozen times. Mostly he didn’t answer, but when he did it was always the same: Damn it, stop yellin’. I keep telling you it’s my chest--my chest.

Although we were desperate to believe him, we were not convinced. Was he clearheaded enough to know if his abdomen hurt? Did the intense pain he felt in his right lower chest obscure pain in his right belly? From his X-rays we already knew the ribs were fractured up and down his right side.

When the chief trauma surgeon pressed gently on the right side of his belly over his liver, Mr. Henry cried out in pain. But that could have been from the shattered ribs rather than damage to the internal organs. Just as the doctor was pondering what to do next--to continue observing Mr. Henry or take him to the operating room for exploratory surgery--the alarms by the bed started to sound. His blood pressure had been stable, but now it was dropping: 120 . . . 110 . . . 90. In near shock, Mr. Henry fell silent.

Run the fluids wide open. Someone get up to the blood bank and get two units, the surgeon barked. He has to be bleeding from more than that lung. Let’s get ready and open him up.

Although a steady trickle of blood continued to drip from the tube draining Mr. Henry’s lung, I knew the surgeon was right: this slight loss was not enough to cause a major drop in blood pressure. The hunt for injury was not over, and Mr. Henry was close to circulatory collapse.

Within a minute two surgeons wearing new sterile blue gowns flanked Mr. Henry. With a few swift slices they made a vertical slit just below his navel, creating an inch-long window into his belly. It was too small to get a good look inside, but it would have to do. Making a larger incision in the emergency room, which is not equipped for major operations, would be treacherous--and cruel to a patient still awake enough to feel pain. The surgeons then slid a tube through the slit and poured in two liters of saline solution. After giving it a minute to slosh around, they lowered the tube to let gravity draw the fluid out.

The solution we had put into Mr. Henry’s belly was clear, but what came out looked like Hawaiian Punch.

He’s bleeding. Call over to the OR and let them know that we’re on our way, said the surgeon. To check major bleeding from internal injuries would require anesthesia and a full operating room staff.

As the trauma team hurriedly packed up Mr. Henry for the OR, I was called to the phone to speak to one of his relatives. I took a swig of cold coffee and procrastinated a minute to decide what I would say. I hate delivering depressing news.

Hello, this is Dr. Rosenthal. Are you a relative of Mr. Henry’s? I asked, probably sounding a tad too official.

Yes, I’m his sister, came a voice that sounded far away. I live in Portland. But the social worker found my number in my brother’s wallet and called to tell me he was there. He’s had such a hard life. . . . She trailed off in tears.

Right now he’s surviving, but it’s touch and go, I said. When did you last speak to him? I wondered whether she knew him well enough to tell me his wishes about respirators, resuscitation, and terminal care. Be an optimist, I scolded myself. He’s not dead yet.

Oh, even when he’s homeless he calls me every couple of weeks. He loves to speak to his little niece, you know. Is he going to die? Will he be okay?

I’m not sure, I nearly choked on my words. He’s on his way to the operating room now. He looks great from the outside, and his mind seems all there. But he’s got bad bleeding in his lung and in his belly. Give me your number and I’ll call you back when I know more. And give us a call if you haven’t heard and get scared.

By now it was nearly 11 A.M. The trauma bay, littered with shreds of clothes and bloody sheets, was empty, and the normal weekend ER visits had begun: hangovers, colds turned to pneumonias, joggers who had fallen on winter’s first ice. Although I knew it was too soon for word from the OR, I kept checking the computer that logs in new samples received by the labs. I typed in HENRY, MANFRED. And as each new specimen was received or its result returned, I was reassured. At least he was alive.

By 2 P.M., when I punched in his name, the stream of specimens from the operating room had stopped. And then, minutes later, new ones starting coming from intensive care. He had made it. I quickly paged the trauma surgeon to see what she had found.

In a mere three hours the surgeons had been able to stop the bleeding by cauterizing torn vessels and sewing up the small tears in his liver and right lung. I’ve already spoken to his sister, she told me. I wouldn’t have said so three hours ago, but now I think he’ll do okay.

Three weeks later Mr. Henry was discharged, his potentially lethal injuries successfully repaired. Because he had no problems with drugs, alcohol, or mental illness, there was no reason for extended treatment. According to hospital records, Mr. Henry had weathered bouts of homelessness after his marriage had broken up several years earlier. Since then, he couldn’t seem to hold the low-paying jobs he was able to get. But the accident won Mr. Henry a brief reprieve from the streets: the hospital’s social workers had found a place for him to stay during his recuperation.

On the day of his release, Mr. Henry walked out of the hospital the same man who had come in--well, almost. The difference was that his body now bore some external marks of his run-in with the bus--two huge scars on his right chest and abdomen.
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