Operating on a Friend at Gunpoint

Dr. Alex Eastman
Faculty Trauma Surgeon, UT Southwestern/Parkland Memorial Hospital

ToughestCase1_AlexEastman Dr. Alex Eastman photography by Adam Fish

I almost didn’t go out with the SWAT team that morning, because I had a long operative day scheduled. I’m a trauma surgeon at Parkland, but I’m also a reserve police officer on the Dallas SWAT team. On that morning in October 2007, I thought, Maybe I’ll let my partner on the team, Dr. Jeff Metzger, take care of the call. Looking back, I’m glad I went.

The house we went to was on Hollywood Avenue in Oak Cliff. It was small and rundown, typical of the houses we often serve narcotics warrants in. The guy we were after had been trafficking methamphetamines and had been violent in the past. But it was really his girlfriend who pulled the trigger.

The shooting happened right at 6 am, when it was still chilly and pitch black outside. My partner and I were standing in the front yard, while other members of the team were already in the house. I actually never heard the shot because it happened deep inside the home, but what I did hear was someone over the police radio yelling, “Officer down! Officer down!”

Then I saw two officers dragging another officer away from the house and near some bushes. When we got to him, he was lying on his back, staring up at the sky. His eyes looked blank. I initially thought he had been hit in the face with a tool. But when he started to exhale, a huge rush of blood came out of his mouth.

He had been shot in the right side of his neck, near his Adam’s apple. The bullet had bounced off the front of his spine and out his left shoulder.
Police officers often say that when you’re in a shooting, you get this tunnel vision. If you can imagine, this was a crazy environment. People are breaking windows and screaming at each other, but you just totally block that other stimulus out. I remember seeing nothing but his neck.

This was a very different environment than when I’m in an operating room where I have light and help. We ended up having to put a tube in his throat with the lights on the end of police rifles serving as operating lights. Basically, we were operating at gunpoint, and that’s crazy.

Normally, when you put a tube in a patient, you first look down his mouth, find his vocal cords, and pass a tube through him. But that’s a problem when blood is welling up in his mouth, and you don’t have suction. So I had to cut a hole in his windpipe to restore his airway, and all I had was a knife, a tube, and a lot of pressure to make that happen.

I cut the hole in his anterior neck, which is 3 or 4 centimeters up from the chest bone, to put in the tube. It took all of a minute and a half to do, but it was a minute and a half that changed our lives.

We see people get hit in the face all the time, but we don’t see someone get shot in the neck every night. Even though you’re a police officer or a doctor and you think you’re ready to take care of things, you’re never used to seeing your friend get shot. This was a guy I hung out with. I knew his family. I knew his kids. Emotionally, I think that’s as big as it gets.

Once we restored his airway, I put an IV in to give him a little medicine to try to make sure he didn’t remember any of this. They took him to Methodist Hospital, where he recovered from his acute injuries, and then he did his rehabilitation at University Hospital–Zale Lipshy.

After about a year of recovery, he came back to work for the police department, but now he’s retired. I don’t see him as often, but I talk to him all the time. I have a bond with him that will last forever.

—As told to Katherine Lagomarsino

Removing a Woman's Stomach

Dr. D. Rohan Jeyarajah
Director of Surgical Oncology, Methodist Dallas Medical Center

ToughestCase2_RohanJeyarajah Dr. D. Rohan Jeyarajah photography by Adam Fish

I was asked to see this young mother. She was 24 years old, and during her pregnancy she had had a lot of trouble with nausea and vomiting. At that time, it was thought to be all pregnancy related. But after she had the baby, her symptoms continued. Her doctor gave her an endoscopy and discovered a stomach cancer.

Before she came to see me, she had already been told that she had cancer by the gastroenterologist and the medical oncologist, but she had not received a complete plan on how to treat it. I had heard about her, about this young woman who had just had a baby, and I was like, “I’ve got to meet her.”

But it was so challenging for me to walk into that room, to face this family. Her mom and dad were there, and they were pretty young because their daughter was only 24. The husband didn’t come because he was “having trouble dealing with this.” I just remember seeing the deep, deep sorrow in her mother’s eyes, because she knows her daughter has this horrible condition. I have two boys and a girl myself, so I saw what I would be feeling if my daughter were to have anything happen to her.

Of all of the fields, medicine is the most human field. There’s so much reading into nuances, reading into phrasing, reading what someone’s face looks like. You can take so many cues from that, and this is not something that we teach well in medical school and residency.

But my patient was a strong young lady who was positive about everything. It was unfortunately a pretty horrible cancer, in that lymph nodes were involved. She wanted everything to be done in order to try to live for her child.

This was one of those cases where some people may have said,  I don’t think surgery will ever be in your future because it has already spread. I told her that we needed to come up with the most aggressive plan possible, and that was chemotherapy followed by surgery.

As a patient, your tendency might be to tell me that you want me to take all of my experience as a doctor, and then take all that has been published and apply it to your case. But do you know what my litmus test is? I ask myself whether this is something that I would do for my mom or my sister.

So she had chemo and lost her hair. I would kid around with her and say, “Wow, your husband must be really confused because he comes home to a different woman every night. Now you’re a redhead!” She’d always laugh. I may not be able to change what’s going to happen, but I can change the way it happens. If I can make it even a tiny bit easier, then I’ve done my job.

After she finished chemo, things looked better, and so we decided to do the surgery. I eventually met her husband. I was kind of worried that he may not be able to relate to me. I’m of Sri Lankan descent, so I’m very dark-skinned, I have a funny accent, and I dress funny. I’m not afraid to wear color. As a surgeon, you want the patient and the family to feel trust in you, so I was happy when he eventually seemed bonded to me.

During the operation, I discovered quite a bit of tumor. It would have been easy to back off because it was a bit risky to do the resection. I had to take out her whole stomach and the end part of her esophagus, and as far as we know, we got everything.

From the human standpoint, walking out and telling this family that we were able to get it out is the best feeling in the world, because for that moment, everyone is just so elated. For a surgeon, it all comes to this one point in time.

As of now, she’s cancer free. Time will tell how this story is going to unfold, because it’s still unfolding. But now she’s doing really well. She’s eating, and she’s at home with her baby girl, who is about 9 months old.

—As told to K.L.

Saving Twin Babies

Dr. Robyn Horsager
Chief of Obstetrics and Gynecology, UT Southwestern Medical Center University Hospital-Saint Paul

ToughestCase3_RobynHorsager Dr. Robyn Horsager photography by Adam Fish

A woman and her husband had come to me for a third opinion. She was in her late 30s, and, after working with an infertility specialist, she was finally pregnant for the first time with twins, a boy and a girl. Unfortunately, when she was three and a half months pregnant, the amniotic sac around the little girl had ruptured. She had come to me seeking advice on how the pregnancy could be managed.

When somebody’s sac breaks, we have to look at two issues. The first is that the sac protects the uterus from getting infected, and when that membrane ruptures, the chance for infection increases. When infection sets in, you can lose the entire pregnancy. That was a concern in this case, although it had already been a few days, and she didn’t show any signs of infection.

But the more critical issue, at least for the baby, is that a fetus needs fluid around it in order for its lungs to develop. Without the fluid, babies can survive in utero but they won’t have enough lung tissue to breathe after they’re born. It’s called pulmonary hypoplasia, and we don’t have a good way to figure out if that’s going to be the case or not.

One solution that had been proposed to her is something called selective reduction, in which you convert this twin pregnancy, where both babies would be at risk if infection set in, to a single pregnancy with the one baby. And that would have been the boy in this case. People had recommended this as maybe the best option.

But that’s a devastating thing to face when you’ve worked very hard to become pregnant. I have a set of twins myself, and I understand how she could feel about having to make a decision to lose one baby to save the other. That being said, if it were truly something that I felt was dangerous to the mother, or if I could have told her that there is a 100 percent chance that one baby is not going to survive, then I would have done that as well.

We did an ultrasound, and clearly the girl didn’t have fluid around her, but the boy’s sac was completely normal. We talked about the possibility of losing both babies and the possibility of both babies being born alive but the girl not surviving because of the pulmonary hypoplasia.
At the end of that visit, she decided to continue with the pregnancy as it was and asked if I was willing to co-manage her pregnancy with her obstetrician. And I said certainly.

I get a lot of people referred to me, and the first thing out of their mouths is “Well, my doctor told me to do this.” My goal is to get people to the point where they are comfortable with their decision. I don’t have to live with the consequences necessarily, but they do, and they need to be given as much information as possible to balance the pros and cons.

She came in weekly, because we didn’t know if the girl was alive unless we looked at her on ultrasound. Then we decided to use a magnetic resonance imaging (MRI) study. We had used them for other conditions, but we thought maybe we’d have a sense of how much lung was present when the baby reached viability, and that would help us make a decision as to how to manage the patient. We had to walk a fine line between doing the right thing for both babies and not jeopardizing the little boy.

The MRI suggested that the girl’s lungs weren’t as developed as we had hoped, and it was a teary day. Still, we continued the course. Ultimately, after about 28 weeks of gestation, my patient had some vaginal bleeding. She was having some premature separation—and not with the girl, but with the boy.

She had a cesarean section, and the end result was that the girl spent only days on a ventilator, while the boy spent a longer period of time in the NICU, which was normal given his sex and gestational age.

Both babies did remarkably well, and a year later, the patient, her husband, and both children showed up in my waiting room—on the twins’ first birthday. They brought me a lovely framed portrait of the babies, and it still hangs in my office. I look at it every day and am reminded that the practice of medicine isn’t always easy, but it’s incredibly rewarding.

—As told to K.L.

Fixing a Man Cut in Half by a Train

Dr. David C. Smith
Medical Director Of Trauma Service, Texas Health Harris Methodist Hospital

ToughestCase4_DavidSmith Dr. David C. Smith photography by Adam Fish

It was a sunny morning in June 2006. At close to 9, we got a call that CareFlite was bringing in a patient, a man in his mid-30s. Fortunately it was at the time of day when the trauma surgeons switch shifts, so we had one guy going off and one guy coming on. I was the guy coming on.

When I know that a big trauma is on its way in, I try to get what I like to call the biomechanics of the crash. It lets you rehearse in your mind what you’re going to need to do to get ready. In this case, the patient had been run over by a train. He worked in a rail yard, and while they were switching some cars, he slipped and fell and was not only run over, but pinned down by one of the cars. It took CareFlite, the Cleburne Fire Department, and the paramedics an hour just to get him out from underneath it.

My first thought when they brought him in was that, although this was going to be a lot of work, this was a survivable injury. He had been practically cut in half just below the waist. Excluding facial injuries, this was the most disfiguring trauma that I’ve ever seen, and I’ve been performing surgeries for 33 years—trauma surgeries exclusively for the last 13 and a half.

He was unconscious and in need of a great deal of blood. We used close to 5 liters initially. To stop the bleeding, we began operating on him right there in the emergency room, before they took him up to the OR, where we then spent the next three and a half hours in surgery.

We removed all of the devitalized, or damaged, tissue. Although that sounds simple, it was a tremendous amount of work because there was so much tissue that needed to be removed very carefully so as not to cause additional bleeding. We diverted his colon to prevent any further fecal output onto his liver, and we patched up a place on his abdomen that was literally one cell layer thick and about as big as a silver dollar.

At the end of that operation, he had lost half of his pelvis, all of his left leg, and about three quarters of his right leg. The best part was that he didn’t sustain an injury to his head or vital internal organs. We had him off the ventilator in three to five days, but in the ensuing 41 days, he had 23 different operations by multiple specialists.

For his wounds, we used VAC therapy—short for vacuum-assisted closure—which allows you to put a low degree of suction over a large open wound to remove the fluid that seeps out of it. That helps keep it from becoming contaminated.

Normally most wounds require one large 12-by-6-inch pad for this type of treatment, but for him, we routinely used four to six large pads every time we changed his dressing. It was the biggest VAC dressing I’ve ever seen in my life.

At one point, he developed problems with his ureter, which is the tube that goes from your kidney to your bladder. There was a leak in it. He had been cut in half so deeply that the ureter was on the outside wall of his abdomen. Usually, it’s very deep on the inside, and for people who know anatomy, that will tell them how bad his wound really was. He ended up losing his left kidney.

He had a very prolonged hospitalization—about six weeks. Because of this, along with the devastating, life-changing thing that had happened to him, I thought it was important for his mental health that he get out and see the sunshine. We put him on a special gurney and took him outside on a regular basis.

In the end, he survived, and after going to rehab here, he eventually went back to work for the same company that he worked for when he was injured. Later on, we did some research and found out that there are fewer than 50 cases recorded in the world’s literature in which people have sustained this type of injury and survived.

Needless to say, he had an incredible will to live.

—As told to K.L.

Performing Surgery With a Robot

Dr. Michael DiMaio
Professor of Cardiovascular and Thoracic Surgery, UT Southwestern Medical Center

ToughestCase5_robot Dr. Michael DiMaio photography by Adam Fish

I’d been following my patient for about six months. I knew about the tornado and how his house had been torn down. He had colon cancer, it mestastasized to his liver, and then a tumor was discovered in his ribcage.

At that time I was getting trained and certified to do the first complete robot-assisted cardiothoracic surgery in North Texas. There are a lot of guys doing it with the prostate and other parts of the body, but not with the heart and lungs.

I thought he’d be a good patient for this. With the robot, you don’t have to spread the ribs or use a saw to open up the bone, and that means patients will have less pain, heal faster, and go home sooner.

But it wasn’t really the tumor that made him a good candidate for this. I wanted someone with whom I already had a relationship and trust. And he’s an optimistic guy. Besides dealing with cancer and his house being destroyed, his finances were completely underwater. But when he comes into the clinic, he always has a smile on his face. You would never know what’s happening at home.

So I called him up and told him that I was doing my first robot and that I wanted him to be my first patient. I had been practicing many, many hours on animals and cadavers, but he would be my first living human patient. He’d been reading about it on the internet and communicating with a circle of cancer patients about different treatments, so he’s pretty tuned in. Not only did he say okay, he was excited about it.

From patients like him, I’ve learned that the human spirit is the most powerful thing going. Just because you have a wonderful physician, wonderful drugs, or a wonderful surgery, if the patient’s spirit, enthusiasm, and confidence are not with you, none of that matters.

The robot is named DaVinci; I call him Leo. He looks like an octopus with four arms, and at the ends of three of those arms are endoscopic wrists. They look like little hands, and they can turn, spin, and grasp. Various instruments—such as scissors, tweezers, or tongs—can be put on each wrist. The fourth arm has a camera on it.

A robot-assisted operation has a much more complex planning process than old-fashioned, big-open-incision surgery. I make the first incision with a knife, and then put a camera in the body so that I can scout around and determine where to put the other ports, or holes. I have to figure out how I’m going to manipulate the arms inside the body, because once I dock the robot over the patient, it’s extremely difficult to change that positioning.

I perform the surgery from a console, which sits about 10 feet from the patient. It looks like a flight simulator, so it’s very different for the surgeon who’s used to getting his hands quote “dirty.” With this, your hands are clean, you’re sitting in a chair, and it’s almost like playing a video game. It’s surreal.

Now imagine my patient’s tumor as a big fungus on the bark of a tree, and then imagine taking various tools to carve that fungus out. In this case, the tumor was sitting right on his ribs. So I put my fingers in these little straps in the console, and my hands are dedicated to moving those endo wrists. I use them to carve, dig, grab, and cauterize an area about inch around where the tumor is growing. I have an excellent nurse, Victor Lopez, who stands at the patient’s bed side and changes out the instruments.

I use my feet as well, so the robot is like a church organ. I tap a pedal that manipulates the electricity, moves the camera in and out, and switches from arms one to two or three. The surgery lasted about two or three hours, and we successfully removed the tumor.

Overall, I think my patient had a good experience with the robot. He’s been positive when he talks to other people about it on the internet, saying this is a good thing to do. I’ve done this surgery on a number of patients since then, and I’m simply amazed. Robotic surgery is truly one of the frontiers of medicine.

—As told to K.L.

Giving A Man Back His Sight

Dr. James McCulley
Chairman of Ophthalmology and Director of the Jean H. & John T. Walter Jr. Center for Research in Age-Related Macular Degeneration, UT Southwestern Medical Center

ToughestCase6_eye Dr. James McCulley photography by Adam Fish

Several years ago a man came to me inquiring about a corneal transplant. As a young man he had worked in the mining industry and had suffered extreme damage to both eyes in a dynamite explosion. He was legally blind, and could only distinguish between day and night.

At the time of his accident he was engaged to be married. He and his fiancé went on to marry, have children and then grandchildren. At some point before he came to me he had had a corneal transplant on one of his eyes that ended so badly that it resulted in him losing the eye altogether. Because he wanted to protect his remaining eye, he went decades without pursuing another surgery.

But there have been major advances in corneal transplantation over the past couple of decades, and so he had come to me about the possibility of restoring his vision. There are now roughly 45,000 corneal transplants done every year in the United States, and the success rate ranges from very high to not so good depending on the underlying disease. In his situation, he would have been in a fairly low prognostic group with the chances of his transplant working initially—and then overtime—at maybe 10 to 20 percent.

A normal cornea, which is the clear dome over the iris and pupil, doesn’t have blood vessels. But many diseases or traumas to the eye result in the blood vessels growing into the cornea. This man had major trauma and therefore blood vessels in his cornea, and when there are blood vessels in the cornea, they increase the possibility of rejection.

Needless to say there was huge risk in doing his surgery. I had about an equal chance of losing his eye on the operating table as I did success. He also could have ended up with a painful eye out of which he could not see. While he couldn’t see with his eye as it was, it was not painful.

But he had no other chance for vision. It was either stay as he was or high-risk surgery. For a reputable ophthalmologist, there can be some difficult decisions to make with patients, and if I felt like there was no hope in doing the surgery, then I wouldn’t have done it. A patient wanting to have surgery is necessary but not sufficient. But it appeared we did indeed have a chance of restoring his vision, and it was a reasonable chance.

This was a much more complex surgical procedure than the average corneal transplant, which is usually done in less than an hour. He had had major trauma, so there was a lot of damage to other tissues in his eye and not just the cornea. His surgery lasted about two and a half hours.

At that time in medical care, we kept patients overnight in the hospital after a surgery of that magnitude. The morning after, I took him to the eye examination room at University Hospital–Zale Lipshy where his wife, children, and grandchildren were all gathered around. And when I removed the patch from his eye he saw his wife for the first time in decades, and his children and grandchildren for the first time ever. All he knew of them were their voices.

It was quite a dramatic situation and obviously very emotional for everyone involved. He had beat the odds and experienced initial and long-term success with the corneal transplant. Up until his death a few years ago, he retained vision that allowed him to function reasonably well.

As told to K.L.