Because in trauma, the body doesn’t die from injury alone, it dies from its own biology spinning out of control.
The Moment It Turns
You know the look.
That moment when the monitor numbers start slipping, when the blood on the floor feels like more than you can give back.
The anaesthetist calls for more units. Someone’s warming saline like it’ll fix the world.
You clamp, pack, stitch, but the patient’s not fighting you anymore. Their body’s fighting itself.
That’s when the pentagram appears.
Not on paper. Not in ritual. But right there, in physiology, five points connected by inevitability:
Coagulopathy. Acidosis. Hypothermia. Hyperkalaemia. Hypocalcaemia.
Each feeding the other until there’s no return.
It’s not a spiral. It’s a trap.
Coagulopathy: The First Betrayal
It always starts with blood, too much lost, too much diluted, too little left that can clot.
Every transfusion unit without plasma is a promise you’ll regret in twenty minutes.
The platelets stop working. The clotting cascade collapses. The surgical field turns into a red fog.
And every stitch you place unravels like a bad idea.
We used to call it “DIC.” We know better now.
This isn’t consumption. It’s dilution, hypoperfusion, and cold.
You don’t clot when you’re frozen. You don’t clot when your pH is 6.9.
And you certainly don’t clot when your calcium’s gone.
Acidosis: The Slow Suffocation
As perfusion fails, the blood turns sour.
Hydrogen ions build up, the heart starts to sulk, and vasopressors lose their bite.
Metabolic acidosis becomes a black hole, everything you do just disappears into it.
Each minute without correction, the myocardium slips a little further into depression, the liver stops clearing lactate, and your resuscitation becomes arithmetic:
one more transfusion, one less chance.
Acidosis isn’t loud. It’s insidious, the slow, silent draining of cellular hope.
Hypothermia: The Cold Knife
The room’s too cold. The fluids are too cold. The patient’s open, wet, and naked under theatre lights that don’t warm anything.
For every degree you lose below 35°C, your coagulation halves in efficiency.
By 32°C, the enzymes are useless. The platelets give up.
And you’re operating on a corpse that just hasn’t stopped moving yet.
We talk about “warming the patient.” We should really say “fighting entropy.”
Because once the cold sets in, it doesn’t just slow bleeding, it invites death to sit down beside you.
Hyperkalaemia: The Hidden Spike
No one ever blames the potassium, but it’s always there, rising silently while you’re focused on everything else.
Cell lysis, massive transfusion, acidosis, renal shutdown, it all feeds the same monster.
Then, out of nowhere, the ECG spikes.
The QRS widens. The heart falters.
You think it’s hypovolaemia, but it’s not. It’s chemical betrayal.
You push calcium, insulin, dextrose, but sometimes, it’s already too late.
The cells you saved hours ago are now killing the heart you’re trying to restart.
Hypocalcaemia: The Forgotten Corner
You’d think we’d have learned this one by now.
Every unit of blood comes with a side of citrate, enough to mop up calcium faster than you can replace it.
Low calcium means no clotting, no contraction, no conduction.
The blood’s there, but it’s useless.
The heart’s there, but it’s weak.
You give calcium gluconate, maybe chloride if you’re desperate, but it’s always after you’ve noticed the numbers slide.
It should be pre-emptive, not reactive.
Because calcium isn’t a supplement. It’s survival.
The Pentagram Complete
When all five points align, there’s a look, a stillness in the room that even the noise can’t hide.
You realize you’re not operating anymore. You’re just documenting physiology’s collapse in real time.
Every parameter that matters is gone.
The blood’s too thin to clot.
The cells are too acidic to function.
The body’s too cold to recover.
The electrolytes have turned lethal.
You can pack, transfuse, and clamp, but the system’s gone.
The pentagram is complete.
Damage Control Resuscitation: Fighting the Pattern
So, what do we do?
We cheat death by changing the rules.
Damage Control Resuscitation (DCR) isn’t elegant. It’s pragmatic. It’s what happens when you stop chasing perfection and start buying time.
- Permissive hypotension: keep the pressure low enough to preserve the clot, high enough to perfuse the brain.
- Balanced transfusion (Fresh whole blood preferable!): 1:1:1, red cells, plasma, platelets. Not after the fact, but from the start.
- Early haemostatic control: clamp, pack, leave. Fix what kills, ignore what doesn’t.
- Warmth and calcium: treat them like drugs, not afterthoughts.
- Reassessment, not reconstruction: get out before physiology gives out.
You’re not winning. You’re stalling the inevitable, until the ICU can pull them back.
But in trauma, that’s enough.
The New Religion of Survival
We talk about DCR like a protocol, but it’s really a mindset.
It’s the acceptance that we’re not gods in the OR, we’re field mechanics, keeping engines running long enough for the next pit stop.
It’s not about control. It’s about restraint.
Because every extra minute of surgery in a patient on the edge isn’t bravery, it’s hubris.
Pack it. Close it. Warm them. Let the physiology catch up.
You can always come back.
You can’t operate on the dead.
And From the Other Side of the Drapes
And when they do survive, when the pentagram breaks and physiology slowly returns, they wake up with no memory of the battle.
They’ll see their scars, maybe feel the ache, but they’ll never know how close their body came to devouring itself.
They’ll thank you, and you’ll nod, but you’ll remember the smell of the cold blood, the monitor tones, the sound of silence before the first pulse came back.
Because for them, it’s a miracle.
For you, it’s the narrowest escape from a pattern you’ve seen too many times, and one you’ll spend the rest of your career trying to break again.
