The emergency radio tones sounded their little tune, such a small sound for a life and death event. Music has always been a reliable and steady companion in my life. A moment before, the phenomenal guitar lead by Garth Webber on Mark Ford’s "Preservation Blues" had been rolling through my brain. Suddenly, the charts changed and the same Mark, now our paramedic, came over the air with the message that the ambulance was heading out code 3 (lights and sirens, full tilt) to a rural home, out a dirt road, for a woman with a stab wound. No further details were available and they would call back from the scene. It was the early 1990’s. My brain suddenly silenced, open and cleared for the next crucial bit of information. It would not be more music.
Living in a low crime area, compared to our larger cities, we don't often have to deal with stab wounds and the cases we do see are often minor, not requiring major surgery. This is fortunate because our technologic and manpower resources are slim. It is also fortunate because even though I appreciate a clinical challenge as much as the next emergency physician, the violence and criminal permeation of the whole scene rattles the spirit. Though I know the job description gives me no choice over my clientele, there are times when I just stop caring about people who not only make no effort to take care of themselves, but also are overtly self-destructive. This was not the case today.
My nurse readied the room with an intravenous setup and cardiac monitor check while I checked on the whereabouts of our surgeons. This case occurred when we had two general surgeons in town. One had been a chest surgeon earlier in his career. Both of them a phone call away, we waited to hear back from the ambulance.
Though the mountain homestead was several miles out a paved road, then one and a half miles further on a dirt road, it did not take long for the ambulance to arrive. Code 3 means to drive as fast as is safely possible. Sometimes, a little faster. Mark called back with the following statement. "We have a forty three year old woman with a Swiss Army knife buried to its hilt in her upper chest. She is in moderate distress with pain and anxiety but her vital signs (blood pressure, pulse, and respiration) are within normal limits. We are establishing intravenous access. Do you have any other orders? Over."
What’s wrong with this picture? A knife buried in the front of the chest and her only problem is anxiety? How could it have missed heart, lung, and great vessels (the big ones-aorta, vena cava, lung arteries and veins)? Or was it poking one of these critical structures and the slightest of movements would cause a tear resulting in rapid and life threatening leakage of blood or air? Would the final moment come with a bump on the road?
Amanda, our patient, was as calm as could be expected while skewered with stainless steel. There was no crying in abject fear of sudden death. She maintained a focused concentration on her task that was to stay calm, not move, and allow the paramedics to do their job. Her husband, David, told the story. Her younger niece was visiting them and had been deeply troubled lately. She had a history of psychotic episodes and was an altogether unstable woman most of the time. Although she was not full blown certifiable recently, a morbid cloud had overtaken whatever wellness she had and the visit with her aunt and uncle was taken to find some family nourishment. In an episode during which this young woman was raving with frustration and misplaced anger, Amanda approached her with open arms offering solace and a simple hug. Her open physical demeanor was met with a sudden thrust of her hand plunging the knife into her chest, just to the left of the upper breastbone area. So much for talking her down. Amanda’s miscalculation of the moment was to cost her dearly.
The paramedics loaded Amanda into the back of the ambulance for the ride to the hospital. Her vital signs remained normal. The ride back over the dirt road, all one and a half miles of it, took Mark over an hour. Driving in slow motion, he used every fiber of his being to take each rock and pothole in slow motion. He knew that a typical bounce could drive the knife tip or blade edge a critical fraction of a millimeter, a tissue membrane thickness, into the lung or aorta resulting in a rapid collapse of circulation or respiration. Every one of scores of potholes was eased into and out of, driving with the brake, ever so slowly. As we anxiously awaited their arrival to our facility, the delay was troublesome. Long after we expected them to be at the loading ramp, there was no patient, and radio silence. What was happening?
What was happening was that Mark did call us while on the dirt road but because of the terrain, the rig was out of radio contact. The signal was going somewhere, but not to the repeater that transmits to our radio. One of our assumptions was that the worst had happened and that Mark was up to his elbows trying to resuscitate Amanda and could not stop to call us. We waited.
After an excruciatingly tedious wait, they arrived at our back door. As Amanda was slowly wheeled in, Mark recounted the trip, read us her vital sign flow sheet, and pointed out the location of her intravenous sites and the dressings on the wound. The sheet was pulled down from her upper chest to reveal the trusty Victorinox camper model Swiss Army knife sticking straight out from her upper chest. It was to the left of and against the edge of the breastbone just below the third rib. There are a lot of important structures there and I wondered why she was doing as well as she was. The only thing of which I was certain was that she needed a surgeon. While the portable x-ray machine was coming down to the ER to take a chest x-ray, I called one of the surgeons. His first response, patient sight unseen, was that she probably needed to be somewhere else where a heart-lung machine would be available if a repair of the heart or aorta would be necessary. The closest thoracic (chest) surgeon with heart-lung bypass equipment is in Santa Rosa, ninety miles south. My surgeon suggested that I get an opinion from our second surgeon in town, the one with chest experience (at a Midwest medical center). The three of us looked at Amanda, looked at the chest x-ray, and decided to get a CAT scan to better visualize the internal structures. The steel, appearing white on the x-ray, was right in the center of the chest surrounded by vital structures. It was a snake in the grass.
The CAT scan was indeed helpful and showed the tip of the blade indenting the vena cava. The vena cava is a huge vein, over an inch across at that point, carrying blood from all of the body back to the heart, to get pumped to the lungs for oxygen replenishment. If the vena cava became punctured, a most serious, life threatening bleed could occur.
With this data in hand, I called the chest surgeon on-call in Santa Rosa. I described the history, physical exam, and CAT scan findings. After hearing the details of the case, he told me that because the vena cava was a low pressure system, the knife could be safely pulled out and any internal bleeding would be contained by the other surrounding structures and stop on its own. I couldn’t help myself. I blurted, "You pull it out. I’m not going to do it here. If you’re wrong and especially if I'm wrong, this is no place to find out when it’s too late."
He told me that I really didn’t have to worry and I told him that I really did have to worry and would he please accept her in transfer. If my chest surgeon was uncomfortable with the case at our facility, I certainly was not about to be the hero of the moment. He finally agreed. Relieved that I didn’t have to pull teeth, beg, grovel, and otherwise sell myself to influence the surgeon to accept her transfer, I set about making the other arrangements and getting her set for the trip.
We decided to arrange air ambulance transport in order to minimize patient movement and jarring along an irregular road surface. The air ambulance company out of Santa Rosa did not have any helicopters available but was able to come up with a fixed wing craft. Amanda was reloaded into our ambulance, slowly driven the six miles to our small airfield, then transferred into the airplane, ever so gently. Slowly and smoothly. Mark offered kind and reassuring words along the way, as it is his nature to do so. With the door closed behind Amanda and the engines humming, Mark signaled to the pilot to open his little window. "Listen buddy, when you get down there, set her down real easy, reeel easy", as he motioned with both hands patting the air slowly. The pilot nodded in acknowledgment and they were off, leaving a lot of crossed fingers behind.
My shift was over before she arrived at the hospital in Santa Rosa so it wasn’t until the next day that I found out what had happened. The surgeon saw the patient in the emergency department, reviewed the CAT scan that we had sent with her, yanked the blade out in the emergency room, kept her briefly for observation, and sent her home. Actually, because the blade was embedded partially in cartilage, the ‘yanking’ was not so easy. When he first pulled up, Amanda raised up with him. The patient’s body had to be held down by a nurse while the surgeon pulled up with everything he had (short of his foot on her chest). She did fine.
There are splinters that cause more trouble that this stab wound to the chest. A one half inch redwood splinter in the hand can result in the need for surgical exploration, wound infection, permanent loss of finger function and big hospital bills to say nothing of lawsuits if things don’t go well. In contrast to that situation in which a small injury can cause big trouble, the above case was an unusual example of a major injury causing almost no trouble. Except, of course, to the sweat glands, heart rates, and stomach pits of our emergency team.
year, on the anniversary of the injury and treatment, Amanda does something
to acknowledge her good fortune. Last year it was a letter
in the local newspaper. It seems that I see her and her husband all the
time. At the grocery store, at garage sales (a major Saturday morning
activity around here), or at the hospital for unrelated visits, I see
her with my visual memory. I see a knife sticking out of her chest, her
eyes riveted in motionlessness. I see her almost dead, undressed, with
IV’s in place, and I see her walking around in her health and happiness.
The mental images are superimposed one upon the other. A four dimensional
picture. Life, near death, then, now, all at once. This is one of the
consequences of my work in a small town. On most days, a walk through
the grocery store puts me in the path of at least several people I have
sewn up, seen naked, counseled about intimate concerns, perhaps saved
or snatched from some threatening jaws. It is an interesting position
to have. I reap the satisfactions of intimate connection with my community,
and I struggle to stay free of too much involvement. There are days when
I crave emptiness. There are times when I envy simple-mindedness. The
rest of the time I treasure my family, my guitar, my cat, and my own
All Rights Reserved © 2004 Jon Sterngold