All Bleeding Stops by Stephen M. Cohn, M.D. explores the effects of trauma with an in-depth look inside trauma centers. Dr. Cohn describes the impact that injuries from car crashes, shootings, stabbings, and other traumatic events have on the patients — and also their family, friends and medical care team. Through sobering narratives, Dr. Cohn paints the true picture of what it means to work in a trauma center.
In the following excerpt, Dr. Cohn details the story of Eddie, a high school student he worked to save after a devastating car accident. Dr. Cohn’s gripping narrative places readers right in the action of a trauma center.
Eddie was on his way to high school on a blue-sky morning. Then he was bleeding to death in front of me, lying belly-open and filled with blood on the operating table. He had been an unbelted passenger, thrown from a pickup truck that was struck broadside by (I later learned) a drunk driver, but at this point, I wasn’t thinking about that. I was operating in this young man’s abdomen and there was massive bleeding coming from behind the liver whenever I lessened pressure. With my left hand, I squeezed upward on the undersurface of the liver while my right hand compressed the aorta (the main arterial blood vessel to the abdomen) down into the spine. If I applied too much pressure on the liver, it cut off the blood returning to the heart; not enough, and we were flooded again with blood. I was running out of hands.
The anesthesia team was frantically trying to keep up with the hemorrhage, transfusing pint after pint of blood. Fortuitously, a transplant surgeon, seeing all the commotion and sensing we could use some help, ventured in from across the hall to provide a much-needed additional pair of hands. We managed to stem this torrent of blood by repairing a huge vein gushing from behind Eddie’s liver and placing some large gauze packs into his abdomen. Eddie’s life was hanging by the proverbial thread. We had stemmed the flow of blood in his abdomen, but Anesthesia reported that blood was now pouring out through his breathing tube and that his oxygen levels were dangerously low despite maximal support. It was clear that he had a major lung injury. A critical decision had to be made. In that instant, I did not have the luxury to consider that this could be one of my own teenagers who had also driven to school that morning. There was no time to reflect on the gravity of the situation or empathize with Eddie’s family, who would be devastated by the loss of their young son with his entire life ahead of him.
To slow the hemorrhage from his lungs, I decided to abort the operation and immediately take Eddie to the angiography suite, where our interventional radiologists could try using balloon catheter occlusion. (These are thin plastic catheters inserted into the bloodstream that have a tiny inflatable balloon at the tip of the catheter which can narrow or dilate a blood vessel). Imagine a large entourage of healthcare providers navigating carefully through the hospital’s hallways, pushing a stretcher loaded with monitors, bagging the patient (manually squeezing in air through his breathing tube), and pouring fluids into this dying 17-year-old as a trail of blood splashes onto the ground. Eddie’s heart stopped multiple times in radiology, but we were able to restore his circulation each time. He barely survived to reach the ICU.
Throughout all this seeming mayhem, the trauma surgeon in charge (me, in this case) must conduct a sort of symphony involving a complex team of healthcare providers in multiple disciplines. I had to coordinate and anticipate all needed life-saving events for this young man, even as I did not (and could not) fully understand the magnitude of all his injuries. In a case like this, survival depends on a combination of knowledge, instinct, resources, and, alas, good fortune. I had to remain calm throughout this process, focusing solely on the challenge at hand and quickly recalibrating my interventions based on the responses of the patient. As trauma surgeons, we do not have time to methodically calculate the risks and benefits of each decision. We must trust our training and experience to make instantaneous, critical, and, hopefully, correct decisions.
All afternoon, we worked relentlessly on Eddie in the ICU with a team of about 25 doctors, nurses, pharmacists, and respiratory therapists. Despite our best efforts, the patient was still losing a tremendous amount of blood. Blood bank personnel provided a continuous stream of blood and plasma. We utilized a cell saver device, which cleaned the liters of blood pouring out of his abdomen and chest and reinfused them into his body. Each time we tried to employ the ventilator, the pressure within his chest was so high that the machine would malfunction, and Eddie’s heart would stop. So, to counter this, medical students took turns bagging the patient. We define a “massive” transfusion as 10 units of blood (about 3.5 liters; a complete blood volume is 5.5 liters) in 24 hours. This amount of blood infusion is only required in a tiny fraction of trauma admissions. In this case, we infused Eddie with over 550 units of red blood cells, plus liters of his recycled blood, more than 35 entire blood volumes (about 200 liters) in all. (This may be the Guinness record for trauma. My next highest transfusion volume in a trauma survivor was approximately 150 units, or 53 liters, in about one hour).
Throughout this eight-hour period, I was able to catch a few minutes to sit with Eddie’s mother in the waiting area at least three or four times to tell her that we were trying everything. All too frequently, our communication with family during CPR is followed by another appearance with the sad news that the patient has passed away. But amazingly, we were able to restore Eddie’s circulation each time. As I left his mother sobbing in the family area, I felt her eyes following me. I knew what I would want if this were one of my kids. Press on! Then, for some inexplicable reason, Eddie stopped bleeding. Perhaps some of his mother’s prayers were answered. We were all astonished by what seemed like a miracle.
But Eddie’s lungs still were not functioning. I spoke with the cardiothoracic team shortly after the patient arrived and asked them to stand by. So, when we stabilized the patient, they put Eddie on the heart bypass circuit (called ECMO). ECMO allows us to load oxygen into the blood as it passes through a machine outside of the body, so functioning lungs are not required. Success! We returned to the operating room the next day to repair injuries not addressed during the first evaluation. After four days on the bypass circuit, Eddie’s lungs improved. He ultimately survived and walked out of the hospital months later. Amazingly, Eddie finished high school on time.
All Bleeding Stops
A gripping portrait of trauma surgeons and their place in the controlled chaos of a trauma center, as told by a 40-year veteran of trauma care.Shop Now