Universal Table

The sound of the pager pierced through the fog of a deep sleep, waking me with a start.

BEEP, BEEP, BEEP. BEEP, BEEP, BEEP.

Is that the trauma page? Can't be - the hospital is supposed to be on diversion because of the nursing strike. Must be dreaming.

BEEP, BEEP, BEEP. BEEP, BEEP, BEEP.

It's the trauma page. Better wake up, better answer it quick. More by reflex than deliberate action, I snapped the light on and pressed the button on the pager. The clock read 2:15 AM. A disconcerting message showed on the digital window of the pager: 5295*1. I recognized the number. A stat page to the ER. 

Shit. This hospital is supposed to be closed. Why did the paramedics bring the patient here? 

5295, 5295. I'd only seen the numbers for a fraction of a second, but it was as if I had known them my whole life as I fumbled for the phone and dialed.

"ER, Janie Stewart."

"Hello, this is Dr. Sticca. What's going on? "

"The ambulance is arriving now.  Thirty-six year old black male involved in an altercation in a bar, stab wound to the right chest. He's in bad shape. Blood everywhere.  BP very low. Barely alive."

"Why did they bring him here?"

"They didn't think they could make it to another hospital. It happened just a few blocks away."

"Have you called the chief resident? "

"He's not in the hospital. Because of the strike, they let all the senior residents go home. You're the only surgical resident here." 

Shit. Shit. Double Shit. "OK, I'll be right there." Jesus Christ. I'm only a second year resident; I can't handle something like this. Where are my shoes? Where's my lab coat? No time to wash up or brush my teeth; got to get there, ASAP.

This wasn't supposed to happen. It was supposed to be an easy day - staying in-house for call was only a formality, due to the strike. While the rotation at Carney Hospital in the Dorchester section of Boston was liked and eagerly anticipated by the Boston University surgery residents, the nursing strike had put a damper on the rotation. Surgical residents live by the dictum "A chance to cut is a chance to cure." Whenever the chance to cut was not present, the surgical residents' interests waned quickly. 

The nursing union had declared a strike about a week ago and the hospital was limited to a few very basic functions without nursing staff to care for the patients. Only two of eighteen operating rooms were functioning, and there were very few inpatients. Elective surgeries were all cancelled. The surgical residents couldn't wait for the end of the strike, but secretly, the relief from the grind of working over 100 hours per week was welcomed - at least for the first week.

It had been an easy day for the second-year surgery residents, starting with rounds at 5 AM. Although there were no surgeries scheduled, the routine for early morning rounds was so engrained that it was hard to break. After rounds and taking care of the few remaining inpatients in the morning, a noon teaching conference and outpatient clinic in the afternoon, the residents that were not on call went home. Since these activities did not have to be worked in between the usual elective surgeries, the day ended several hours shorter than the standard twelve-to-fourteen hour days. (In 1985, mandatory eighty-hour workweek maximums for physicians-in-training did not exist.) During the strike, the residents actually arrived home by 5 PM. Our wives and children didn't know what to make of it.

General surgery has long been viewed as the toughest of all specialties to train in. Originally designed by Dr. William Halsted, the father of American surgery, in the early 19th century, the training has changed little since then. The five years are the longest of any specialty for basic training. Nowadays, as many as seventy percent of surgical residents go on to train in a surgical subspecialty for another two to three years, extending the rigors of training even longer. Viewed as masochists by other trainees in medicine, surgeons take a perverse pleasure in knowing that they are expected to work the hardest and have the most difficult hours of any residency in medicine.

Every medical student has to make a decision as to what specialty he/she will spend the rest of his/her life practicing by the end of the third year of medical school. This is probably not the best time, as by the end of the third year each student has only had a short time to experience the major specialties in medicine: pediatrics, obstetrics and gynecology, surgery, psychiatry, internal medicine, and family practice. Because the application and interview process for specialty training occurs during the fourth year of medical school, this decision must be made by the end of the third year. 

For me, this decision was more difficult than most. I had started medical school a few years later than the standard age of twenty-two. I was married the year before I began medical school and my son, our first child, was born while I was a third-year medical student. Before doing my surgical rotation, I was aware of its grueling work hours, so surgery was not initially a consideration for me. I didn't think I could bear to be away from my growing family.

But a strange thing happened during my surgery rotation. I fell in love with it. The surgical mentality, the hard work, and the ability to cure a disease process with an operation all appealed to my persona. This, coupled with comments from my surgical preceptors on my better-than-average technical abilities, gave me cause to reconsider my previous plans. After many long discussions with my wife, I realized that I would not be happy in another specialty. Her consent and encouragement was the last bit of evidence I needed to pursue a career in surgery. Despite these convictions, there were lingering doubts about this choice. Could I do it? Would the training be too tough for me and my family? Would I be able to do what was necessary in an emergency situation? I loved the work, but the 120-hour workweeks only reinforced my uncertainty.

There is a well-defined caste system in surgical training. Each year of training brings on different levels of technical tasks and patient care responsibilities. As the lowest members of the team, interns or first-year residents take care of the pre- and postoperative patients, seeing them daily, gathering lab and x-ray reports, writing notes, and doing other menial tasks or "scut" work. Their operative experience consists of easier cases- appendectomies and hernia repairs- but even then they are at the mercy of the chief resident, who may or may not assign these cases to the wanting intern. Each year, if the resident is fortunate enough to get promoted to the next level of training, the degree of responsibility and difficulty of surgical cases increases.

The fifth-year chief resident controls most aspects of the surgical service, including distributing the workload, assigning the surgical cases, and making the call schedule. In addition, the chief supervises and teaches all residents below him and is ultimately responsible for all aspects of the surgery team. This responsibility can be a heavy weight to bear, often making the chief cranky and irritable. The chief resident can make the junior residents' lives a living hell or a fantastic experience, all depending on his/her personality, sense of fairness and organizational ability. All surgical trainees, including the chief resident, are supervised by attending surgeons who have completed their surgical training, but there is an unwritten rule that the attendings will rarely interfere with the chief resident's authority over the junior residents.

The ER was about a five-minute walk from the call rooms. I made it in about sixty seconds by running down the five flights of stairs two at a time, a trick I learned from Charlie Eaton, a chief resident that I actually liked and respected. 

Upon arriving in the ER trauma room, the scene was chaos. The receptionist's description was accurate - there was blood everywhere. It seemed to be coming from a gaping stab wound in the right axilla (armpit), which had obviously lacerated the major artery and vein running from the heart to the right arm. The victim was unconscious and barely breathing, his blood pressure was low - in fact, barely obtainable.

The nursing staff all looked up when I entered the room, waiting for someone, usually the chief resident, to take charge. As a second-year resident, I did not have the experience or training to take this type of responsibility. But there was no one else to do it. With the hospital closed, there were no other surgeons around to take over. The patient would be dead in a matter of seconds. His heart rate was already slowing, indicating an impending cardiac arrest. Sure, I had seen and assisted on a few traumas as an intern at Boston City Hospital, but that was different. There was always someone else there to take the responsibility and give the orders. At Boston City, all I had to do was obey orders, watch and learn. Now it was me in charge, with no one to pass the buck to. But there was nothing to lose. In a minute or two this patient would be dead, unless something was done, and quick.

What's first? The ABC's of trauma, a sequence that is pounded into a surgical resident's brain a thousand times: Airway, Breathing, Circulation. Find an airway to get oxygen to the lungs first, or everything else will be useless. Without oxygen in the lungs to get absorbed into the blood stream and circulated to the vital organs, life is not sustainable.

No difficult thought process here. An unconscious patient who is not breathing adequately - intubate him and put him on a ventilator. 

"Nurse, where's the intubation tray."

"Right here, doctor. Which blade do you want?"

"I will take the straight Miller blade. Can someone extend the neck?" 

As I pried open the mouth, a rush of vomitus was expelled. I was ready to vomit myself.  "Great, OK, I need the suction, quick."

With rapid suctioning, I was able to clear the airway, but even then there was no spontaneous respiratory activity. I knew that he needed to be intubated. I had practiced intubation on a manikin many times, but this was different. Manikins didn't have French fries in their throat. Manikins didn't die if you couldn't get the tube in. After clearing the airway, I was actually able to see the vocal cords, a critical step in getting the tube in the right place. Even more surprisingly, the tube slid into place in the trachea without difficulty. 

"OK, I think the tube is in the right place, can someone listen to the lungs for breath sounds?"

"It sounds good, doctor," the nursing staff said, and I sensed a new tone of respect.

"OK, connect the tube to the vent, use these settings - Rate -16, 02 -100%, PEEP-5."

Maybe I can do this.  OK, what's next? Airway - OK - the tube is in good place. Breathing - OK - the patient is now on the ventilator and has good respirations. Circulation - major problem. 

"Nurse, can you tell me what the blood pressure is?"

"Doctor, we can't get a blood pressure."

The monitor revealed that there was still electrical activity in the heart, but there was little or no blood in it. Hemorrhagic shock is an interesting phenomenon. If there is massive blood loss and the heart has no fluid to pump to the vital organs, everything stops. This patient was in the worst stage of hemorrhagic shock.  He had probably lost seventy-five percent of his blood volume and didn't have enough blood in his vascular system to keep the circulation going. He needed fluid, lots of fluid.

"How much fluid has he gotten?"

"None, doctor. We can't get an IV, his veins are all collapsed. We've tried several sites."

"OK, no blood pressure, I guess we should start chest compressions. I need to get some IV lines started, and fast. Do you have a cutdown kit?" 

"Yes, Doctor, right here"

"Open it.  Quickly." I tried to act calm.  If ever there was a need for Nam lines, this was it. I had heard and read about "Nam" lines several times. This was a rapid and crude form of an IV that could be used to give large volumes of fluid in seconds. They were first described in the Vietnam War when badly wounded soldiers in hemorrhagic shock needed rapid infusions of large volumes of fluid and blood. The concept is simple. Place the largest tube possible in the most accessible vein that can accommodate it, and then use it to give the fluid and blood as quickly as possible. In Vietnam they had discovered that it was a waste of time to fool around with the standard intravenous catheters to give these volumes of fluid. The IV catheters were so small that they only served as a bottleneck for the large volumes of fluid that were needed.  These IVs were fine for the usual fluid volumes that were given, approximately 100-200 cc/hour, but when giving 100-200 cc/minute, they couldn't handle it.

Basic fluid mechanics says that the larger the diameter of the tube, the more fluid that can flow through it. The solution reached in Vietnam was to use the IV tubing directly, which was at least ten times larger than even the largest IV catheter. The tubing was cut tangentially and inserted directly into the saphenous vein, a large vein just under the skin of the inner aspect of the thigh. With a little practice, these could be placed in thirty to sixty seconds. I had only seen this done once before at Boston City. I didn't have time to practice. 

"I'm going to put Nam lines in," I said hesitantly.

Eyebrows raised. There were several questioning glances around the room. There weren't many alternatives. The patient was dying in front of us, for lack of fluid volume.

"OK, doctor, tell us what you need."

"Get that IV tubing over here and hook it to a large bag of normal saline." As I slashed the inner aspect of the thigh with the scalpel, I prayed that the saphenous vein would be where it was in the anatomy books. A brief moment of dissection, and Yes, there it was. A quick incision into the vein and insertion of the tube and the fluid was running in. 500 cc in about two minutes - great. The second Nam line in the other leg was even quicker. With two Nam lines, both fluid and blood could be given rapidly. 

"Doctor, we have a blood pressure of 70 systolic, and the heart rate is down to 120."

"Great, give two units of O negative blood and keep the normal saline running in as fast as possible." OK, now we're cooking with gas. This guy might make it. The blood pressure was coming up and the heart was now pumping efficiently. He had only been about two to three minutes without adequate circulation, not enough to cause brain death, but it was impossible to tell until the patient was stabilized and woke up. In most circumstances, the human brain can tolerate up to four to six minutes of poor blood flow without permanent damage. I hoped that the critical time for brain injury had not been reached.

"What's the blood pressure now?"

"90/60 but we have a problem."

"What?"

"Look at his axilla, there's blood gushing out all over."

Right - the injury that had caused all of this was still there. While the patient was in hemorrhagic shock without any circulation, no blood came from the lacerated blood vessels in the axilla. But now that circulation had been restored, the spickets were open again and the blood was pouring out. 

I pointed to one of the young orderlies, watching in awe. "Joe, come here, get some gloves on. Grab these sterile towels and put pressure under the arm, here." Most bleeding can be stopped with direct pressure, and this situation was no different. With pressure on the lacerated blood vessels in the axilla, and fluid infusing, the blood pressure and pulse began to normalize. This guy can make it! There still were a lot of hurdles to get over: he could develop organ failure, he might have brain damage. But he was doing better, and we were doing everything we could.  

"OK, call the OR, tell them to get ready because we're coming up. Has anybody called Dr. Carrol and the chief resident? Who's the chief on call tonight? Rob Grasberger.  OK, get him on the phone. Joe, keep pressure on those vessels." It was getting easier to give orders. And surprisingly, people were listening. This was getting better by the minute.

"Doctor Sticca, we have Doctor Grasberger on the phone. Can you talk with him?"

My hands were covered in blood, and I couldn't stop to hold the phone. "Yes, hold the phone to my ear." I told Rob the situation. He was a good chief resident. Not only would he pitch in and help when the shit hit the fan, he wasn't overly impressed with himself and would spend time teaching and guiding the junior residents, as a chief resident should. "We put some Nam lines in and he now has a reasonable blood pressure and pulse. He's still actively hemorrhaging from the axilla. We're controlling it with direct pressure, but this guy needs to go to the OR."

"You put Nam lines in?" Rob said with some incredulity.

"Yeah, he was ready to code, I had no other choice. He's doing better now. Blood pressure 110/60, heart rate 110. We've given him eight liters of saline and four units of blood. I thought this guy was dead when I first saw him, but now I think he might make it."

"Does he have any brain function?"

"Can't tell right now. He was comatose when he came in. He was severely hypotensive only for about three minutes. His pupils are reactive but he hasn't woken up.  We've sedated him now, for the OR."

"OK, I'll be there in ten minutes. Is Mitch Carroll coming in?" Dr. Carroll was the chief of surgery, also the attending surgeon on call that night and the one to make the final decision to operate. The chief resident could call him Mitch. I referred to him as Dr. Carroll.

"Yeah, they have called him. I think he is coming in. Do you want me to call him?"

Usually the chief was the one to communicate directly with the attending surgeon, especially for important decisions such as this. 

"No, I'll call him. Meet you in the OR."

The situation had calmed down a little in the ER trauma suite. With a stable pulse and blood pressure, I could take a deep breath and try to relax a little. I was still a little shaky, but the patient was doing better, the trauma team was working well together, and I was rapidly adjusting to the role of the team leader. "OK, have the labs come back? We need to get this guy packaged up and into the OR. Has anyone heard from Dr. Carroll? Joe, are you OK? Are you keeping pressure on the bleeding vessels?"

By the time we got to the OR, the entire team was there: Dr. Carroll, Rob Grasberger, the anesthesiologist, and the nursing staff and scrub tech. When the patient arrived, they took over, and I was again relegated to the role of a second-year resident.

And that was OK. It took me some time to realize the magnitude of the last half hour's events. We may have saved a life. I used some of the knowledge from over 5 years of studying and training to actually save someone's life! The hard work, the sleepless nights -  they had finally made a difference. It felt good, very good.

I was right about the injury. The knife had lacerated the axillary artery and vein. Both of these could be repaired, which took about two hours in the operating room. I watched and assisted as Rob and Dr. Carroll performed the repair. Fortunately, the closely adjacent axillary nerves, which control the function of the arm, were not injured. With blood flow reestablished, the patient would likely recover with intact function of his arm and hand. By 6 AM the patient was in the Intensive Care Unit, recovering from surgery. 

As we were leaving the OR, Rob Grasberger and Dr. Mitchell asked me about the events in the emergency room. I recounted them in more detail, explaining my trepidations during the resuscitation in the ER, but they both felt that the management had been appropriate for the situation. In fact, they were actually impressed.

"This guy is lucky you were there," said Dr. Carroll.

Heady stuff for a second-year resident.  At some time during their training almost every surgical resident experiences doubts and feelings of inadequacy about his/her future ability to function as a surgeon, especially in emergent life or death situations. Mine were fading quickly.

Although I had only two hours of sleep in the past thirty-six hours, fatigue was not an issue. I was still riding an adrenaline high from the emergency room. I spent the morning in the ICU with my patient, monitoring his progress and waiting for signs of brain function. If he woke up and demonstrated higher-level brain function, he would make a complete recovery. This could take days, or even weeks, after an episode of shock.

Later that morning I spoke with the police investigating the incident. I found out that my patient was an accountant who was at a local dance bar and was mistaken for another man who was involved with the assailant's girlfriend. He was attacked with a switchblade in the low lighting of the dance floor. The drunken assailant had been found and arrested. In my limited experience with trauma, I had noticed that almost always, drugs, alcohol or women were involved. This case was no different. I spoke with my patient's family: decent people, and very concerned. I explained the injury to them and the possibility of brain injury. They understood that at that point, it was a waiting game. 

Word had spread around the hospital quickly through the ever-present gossip trail. People who I didn't even know viewed me with a new sense of respect, and several approached me in the ICU congratulating me on a job well done. I tried to minimize my part, not knowing if the ultimate outcome would be good.

A little after 1 PM, the patient started to wake up. He first moved his extremities, then began to open his eyes. In another hour or two, he was able to nod yes or no to questions. My heart raced. This guy WILL make it! He was even able to move his right arm and hand - he would recover completely. Both his family and I were ecstatic.

When I finally left the hospital around 7 PM that day, my patient was stable and improving every hour. I took a deep breath of fresh air, squinting in the sunlight. Sunlight, not something a surgical resident experiences very often. The drive home was only fifteen minutes, but I was beginning to feel the effects of the continuous high level of activity over the last two days with little rest. As usual, I had missed dinner with my wife and children, but the microwaved leftovers were still good. The kids climbed up on my lap as I sat in the living room, and despite having my one and three-year-old playing on my lap, the exhaustion coupled with a full stomach was too much.

As I drifted off to sleep, I was feeling pretty good. My patient was recovering in the ICU, and it was because of my ability to use my training and skills to help my fellow man. Maybe it wouldn't always be this way, but right then, the euphoria was intoxicating.  Maybe I had made the right decision to become a surgeon.