Ive seen crimes, criminals, brain death, organ donation, burns, scalping via commode, bike accidents, motor vehicle collisions, and all manners of trauma and morbidity in between but this last case has a little bit of everything (except brain death and organ donation. Probably) so it was a good case to close it all out with.
A 40yo male with sickle cell disease complicated by Hepatitis C and IV drug abuse was admitted to Interfaith Hospital for a sickle cell crisis. He was at the hospital for 4d and stable when he had an "unwitnessed fall from ground level" and was found in his bathroom. Well this fall really seems to be "went to smoke crack in the bathroom where he was then assaulted by an unknown assailant" but since no one saw the incident and he was just found down, they went with "unwitnessed fall." Well this "ground level fall" resulted in a severe subarachnoid hemmorhage, 1-2 R rib fractures, left 6-8 lateral rib fractures, 9 left posterior rib fracture, bowel wall edema, and hemothorax. He was transferred to Cornell-NYP after a severe regression in his alertness ending in non responsiveness where he was initially picked up by neuro-ICU for the head bleed despite the trauma. SICU requested he be transferred and had to argue with Neuro to get the patient. He was finally transferred after it was seen that he had a complete left lung opacification and malpositioned left chest tube that he arrived with (that still put out 800cc). He began to bleed massively until a massive transfusion protocol was begun on him. He eventually required 21u of blood over the next 36h. Needless to say, he wont be sickle for a while after that. Thoracic surgery was called due to the opacification and massive hemothorax and despite the need for mass infusions, hemorrhagic shock, and the setting of abdominal-thoracic compartment syndrome they did not do a thoracotomy the first time. They opted for a VATS (Video Assisted Thorascopic Surgery) where over a liter of clot was evacuated and no source of the bleed was found. The thoracic fellow insisted that the bleed was not surgical thoracic and instead medical, despite medical bleeds rarely if ever requiring 20+ units of blood. Finally with full on shock and compartment syndrome thoracic finally agreed to take him for a thoracotomy while surgery went in for a laparotomy. Immediately upon cutting the abdomen and thorax he depressurized and immediately returned to hemostasis. One fellow described cutting the abdomen for the laparotomy as "you know those snakes in a can of peanuts toys? How the snakes just explode out when you pop the top? Yeah, thats how his bowels were." But he significantly stabilized upon the thoracotomy. He was still bleed so severely that they kept the abdomen open before returning him to the SICU. He more or less had a bedside exploratory lap twice in the next 36h since he kept bleeding so heavily that he needed to be unpacked, examined, cauterized, repacked, and VACed twice. That was a pretty crazy procedure to see on the unit and not in an OR where most ex-laps occur. Needless to say, this patient caused some pretty big tensions and dramatics between the SICU and thoracic surgery with the thoracic fellow almost getting into a brawl with a SICU resident. It was pretty ridiculous.
Despite all the blood, guts, and disease Ive seen in my tenure at the SICU, this last patient took home the prize for most gut wrenching trauma: a tourist from Spain was getting ready to go home and while crossing the street, her foot alone got run over by a bus. Somehow, the bus wheel degloved her foot which is exactly as it sounds- her foot skin came off like a rubber halloween prop in one whole sheet including cleanly amputated toes inside her shoe. Remaining, was a neatly deskinned foot tendons, vasculature, and all out in the open. It was a very visually arresting injury. I do not recommend Googling. Plastics could do nothing about the toes, but they tried to skin graft her degloved skin back onto the foot. Hopefully, the graft will take, but if it doesnt they will need to amputate the foot.
Overall, this program was poorly run, confusing, and very disorganized, but I managed with sheer luck to wind up in a good unit, with a fantastic team, and by coming back to the same people, patients, office, and unit day after day I managed to get a very broad and detailed view of at least how things work in the SICU and trauma teams. I do believe this program needs to figure out if it cares more about having us understand the clinical care side of things or form research collaborations with Weill Cornell clinicians. Trying to do both lead to stress and confusion and not being able to successfully do either. Hopefully, subsequent classes will be able to enjoy a smoother experience.
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