A Typical Saturday Night in the ER

The Bugger Missed! 

Saturday night in the big city is the time for partying, for unwinding at the end of the week. Families and friends get together to socialize and quaff a few beers, recount the events of the week and argue. The Winnipeg General Hospital was located in the core area of the city, noted for its Saturday night volatility. Week-end call was the proving ground for residents in the ER, surgery, anesthesia and ICU, when they learned their trade by full immersion. Too often happy family parties turned into deadly brawls; mayhem and violence fueled by a few too many beers. At times our stalwart citizens resorted to lethal weapons and the knifings, gunshot wounds and beatings that resulted gave the on-call teams plenty of practise in the management of trauma, and usually keep them busy well into Sunday.

Alex C. was a fairly typical example of Saturday night celebrations gone awry. He was brought to the ER by ambulance, full lights and sirens, from a somewhat seedy area near the hospital. Initial assessment was started even as he was being wheeled into the trauma room. He was rapidly exsanguinating from what appeared to be a gunshot wound in the right side of his abdomen, just above the umbilicus. Although substantial external blood loss was obvious we were sure there was much more inside his abdomen. He was on the verge of hemorrhagic shock: cold, clammy, vaso-constricted, with a thready pulse and undetectable blood pressure. No other signs of injury. At that moment a detailed history was unnecessary; the police would see to that. But in any case, he was confused and incoherent, either from booze (the aroma of which clung to him like dog hairs to a carpet) or shock. On quick assessment he appeared to be relatively young, about 30, a little below average size and fortunately in good physical condition. The sort of sport he had been indulging in was not well tolerated by the old and infirm.

Emergency treatment for this sort of trauma is pretty straightforward. First priority is to insert at least two or three of the largest intravenous cannulas possible, in whatever veins, peripheral or central, that can be located. The ER nurses and physicians are pretty good at this, and usually it’s the nurse who gets the first line. From that point it’s a struggle to transfuse enough saline, colloid and emergency blood to keep ahead of his ongoing internal blood loss until you can get him to the operating room. Surgical exploration is the definitive treatment. The OR nurses were counting the instruments and the surgical residents were scrubbing as we wheeled him out of the elevator. Anesthesia induction is critical in these cases, the wrong agent can kill the patient. That was the unfortunate experience when sodium pentothal was introduced to field anesthesia at Pearl Harbor. It inhibits the reflex mechanisms that maintain circulation and cardiac arrest quickly follows. Fortunately ketamine had just been approved, and ketamine, muscle relaxants and an endotracheal tube had Alex ready for surgery in minutes.

A 12-gauge shotgun shell primed with #4 buckshot at close range can do a lot of damage. After the bleeding vessels had been located and ligated there was a long night’s work ahead to find the multiple holes in his bowel and repair/resect and re-examine. The surgical residents had plenty of practice in suturing bowel that night and well into Sunday.

I didn’t get to see Alex again until Monday. Since I was the junior member of the team it was left to me to complete the charting, that is to record a proper history and physical. He was awake and conscious, though obviously painfully aware of an abdominal incision that extended from his xiphoid (the lower end of his sternum) almost to his pubis. (The surgical maxim is big surgeon-big incision, small surgeon-small incision). Although movement was particularly uncomfortable, he was in reasonably good humour and prepared to talk.

We got the usual pleasantries of introduction and past medical history over with fairly quickly. Then I got to what I considered the gist of the matter; how did he manage to get himself shot at close range by a 12-gauge shotgun. I didn’t ask in those words of course. I said something like, “Alex, do you remember being brought into the hospital?” “No.”

“Alex, do you remember what you were doing Saturday night?” This caused him to reflect a moment, but he nodded affirmatively.

“Alex do you remember getting shot?” There was again a minute’s hesitation. “Did I get shot?”

“Yes, Alex, you were shot in the belly. Tell me what you remember about Saturday night.”

Alex thought for a minute, as if he were not accustomed to long speeches. “Well my brother-in-law and me were having some beers, eh! We usually have a few beers and talk about hunting. I’ve known the bugger all my life and we hunt together every fall.” He stopped then as if that were the end of the story.

“Go on, Alex, what happened next?”

“Well, we got to arguing about who was the best shot, eh! Well, I got to admit, I like my brother-in-law, but he can’t shoot worth shit. I got all three bucks that we shot last year.”

“Go on, Alex.”

“Well, I told him that and he got real mad. Said I was a lying little shit and he would kick my ass until it was up between my shoulder blades.”

“Yes, then what happened?”

“Well, I didn’t like that much so I grabbed a knife and told him: you try to kick my ass you bugger and I’ll cut your balls off.”

“Yes, and what did he do then?”

“Well, then he grabbed his shotgun and started waving it around and shouting at me, ‘don’t you come any closer with that knife you little shit. You take one more step and I’ll blow your bloody head off’.”

“Yes, and then what happened?”

Then Alex did the most unexpected; he started to laugh. Not just a chuckle but uproarious, uncontrollable laughter. When you laugh the first day after a major abdominal incision it hurts. It doesn’t just hurt; it is agonizingly painful. Your belly feels like its coming open again. Alex hugged a pillow to his belly as tightly as he could and grimaced with pain but it took some time before he regained control.

I was completely perplexed. “Alex, what’s so funny? What the hell are you laughing about?”

He almost started to laugh again, but his belly was still on fire. Choking back his mirth, his reply clearly indicated that he was satisfied he had won his point.

“The bugger was waving his shotgun around and shouting at me, ‘you take one more step and I’ll blow your bloody head off’. Well I did and he missed. I told you, he can’t shoot worth shit.”