Sometimes Small Is Great!

Imagine this: It’s noon, you are homeless and hungry, and you are standing in line at a local food kitchen. Suddenly, a young man walks up and jams a hunting knife through your shirt and directly into your heart. As you fall to the ground, your last thought is, “Why did this happen to me, and, of all places, in a small town? I am going to die.”

The assault described above actually happened in the small town of Aberdeen, WA, population 17,000, which is served by the 37-member Aberdeen Fire Department (AFD) and 140-bed Grays Harbor Community Hospital (GHCH). Did the patient die because of this small-town location? Not even close.

The Event

At 12:39 p.m., the AFD received a report of a man stabbed in the abdomen at a local parish. At 12:41, Medic 7242 with paramedic/firefighters Dave Swinhart and Isaac Gustafson; Engine 7205 with Captain J.R. Streifel, engineer/IV tech Brian Swanson and firefighter/IV tech Ron Smith; and Battalion 7232 with Battalion Chief/EMT Damon Lillybridge were all dispatched to the scene. Just as the units went into service, dispatch updated the information to a “stab wound to the chest.”

At the Scene

The Aberdeen fire units staged momentarily to allow law enforcement to secure the scene, but still made patient contact two minutes after being dispatched. The patient was found supine and unconscious, with an approximately two-inch laceration/puncture wound produced by an eight-inch hunting knife just distal to the xiphoid process. In spite of the weapon size, there was little to no bleeding from the wound, and the patient presented with a respiratory rate of about 30, notable JVD and a weak radial pulse of 130.

The patient was quickly moved via scoop to a backboard, onto the gurney and loaded into the medic unit, where he was stripped and a trauma dressing applied to the wound. Respirations were assisted with a BVM and supplemental O2. A call was made to activate the GHCH trauma team. Two 14-gauge IVs were placed in both ACs, with one-liter bags of normal saline hanging in pressure bags. Medic 7242 was en route with a scene time of seven minutes. Paramedic Isaac Gustafson used rapid sequence intubation to secure the patient’s airway with an 8.0 mm ETT. Vitals were taken, and an EKG showed the patient in sinus tach, with a pulse of 124 and BP 85/58 while being bagged. Medic 7242 delivered the patient to GHCH at 12:55 p.m.—a mere 14 minutes after the 9-1-1 call was received.

At the Hospital

In spite of almost 1,500 cc of normal saline infused in the prehospital setting, the patient arrived with a systolic BP of about 70 and was taken to the operating room at 1 p.m., with a pre-op diagnosis of stab wound to the chest, shock and cardiac tamponade.

The patient was given a general anesthetic without complications. Assisted by Akbar Ali, MD, surgeon Juris Macs, MD, made an incision between the xiphoid and the umbilicus that was rapidly carried into the peritoneal cavity, where a bulging pericardial sac was noted, which was immediately aspirated of blood. An incision was then made from the suprasternal notch connecting with the abdominal incision, and a sternal cutting knife was used to do a midline sternotomy. The innominate vein was dissected and a rib spreader was inserted.

The surgeons opened the pericardial sac and inserted a small Foley catheter through the still-pumping hole in the heart. The Foley cuff was inflated with approximately 3 cc of air, providing effective control of the bleeding. A large clot in the pericardial sac was evacuated and the laceration to the heart repaired. During surgery, blood loss was estimated at about a unit, but a Cell Saver was used to aspirate the blood, and about 250 ml of concentrated red cells were returned to the patient, along with two units of crossmatched O-positive packed cells. After closing the chest, a chest tube was placed, a subclavian line inserted and the patient was transferred to the ICU.

Other Issues and the Outcome

Additional issues surfaced that added to the patient surviving the outcome. History obtained from a number of relatives in the waiting room indicated that the patient smoked and was addicted to “any and all drugs, but otherwise healthy.” Their observations were confirmed, as the patient tested positive for amphetamines and opiates, as well as hepatitis C. To further complicate matters, a sputum culture grew Klebsiella, along with methicillin-resistant S. aureus and streptococcus pneumonia, resulting in a combination of antibiotics being administered prior to the patient being discharged.

In a time when large seems to be the “in” thing, from large homes to large trucks to large everything, you might think that you’d have to live in a large city to survive a catastrophic event like the one described. However, this whole deal went down in small-town America. Make no mistake, no single part of this event made the difference; it ALL made a difference. Outstanding work in the prehospital setting by the EMS team from Aberdeen FD, coupled with outstanding work in-house by the trauma team at Grays Harbor Community Hospital, showed what excellence in prehospital emergency medicine is all about. This is mirrored by the fact that, from the time the 9-1-1 call was placed until the patient was being treated in the OR, a mere 21 minutes passed. A small-town fire department and a small-town community hospital put it all together to show, without a doubt, that sometimes small is great! Until next month…