Emergency!

by Mark Brown, MD

  I suspect you wanted to be home as much as I did, but there wasn’t any grumbling. We saw ninety patients that night. Most were sick, some weren’t. For a few it was their last Christmas. The kitchen sent Styrofoam trays, holiday dinners for the staff, since no one could get away. When I finally left at 2 A.M., most of the trays were still sitting there, untouched.

  I thought about us as I drove home. I thought of how we work together through the good and the bad, and of the experiences that bond us to each other. I realized that I had spent my Christmas with a great bunch of professionals I am proud to call friends. I realized how much you all mean to me and I just want to say thank you.

  DAN CALIENDO, M.D.

  Wichita, Kansas

  IN MEMORY OF J. W.

  8:07 A.M.: A call comes in over the radio, “Code three.” We are getting the victim of an auto-vs.-pedestrian accident, a seven-year-old girl. “Severe head trauma” is the description. Later we will find out that she had been dropped off at school by her car pool, had walked out between two cars to cross the street, and had been hit by the father of a classmate as he pulled up to drop off his own child.

  The ETA is fifteen minutes. This patient will almost certainly need to be put on a ventilator. I scribble some orders on another chart, pull off my white coat, grab my stethoscope, and head for the resuscitation suite. I am the junior ER resident today, and my job is to take care of the patient from the neck up, including managing her airway. The senior resident will run the resuscitation, making management decisions.

  8:09: I don a lead jacket to protect myself from all the X rays we’ll be shooting, put on two pairs of gloves, and begin assembling all the equipment I think I’ll need. I’m very nervous, because I haven’t intubated many children and I’m not sure how big she is or what size endotracheal tube I’ll need. I go through a formula in my head and grab a size 6 tube, with a 5.5 and a 6.5 for backup, placing them within easy reach on a Mayo stand. My hands are shaking. I insert a flexible metal stylet into the 6 tube to help guide it, and check the cuff balloon to be sure it inflates properly.

  8:12: I am relieved to see the respiratory therapist arrive. She puts together a pediatric bag and mask to ventilate the patient by hand if necessary while we are getting ready to intubate. I hook up the suction, check to make sure it’s working, and stuff the tip under the gurney mattress, where I can easily reach it.

  8:14: I am rummaging through the drawers, looking for the right size laryngoscope blade to fit in this patient’s mouth, so I can see her vocal cords when I intubate her. Finally I settle on a Miller 2, attach it to a handle, and make sure the light works. A Macintosh is also out and ready as a backup. The senior resident walks in, looking very cool, and puts on some lead.

  “Have you called pharmacy?” he asks the nurse in charge.

  “They’re on their way.”

  “Why don’t you draw up some etomidate, sux, and atropine. We’ll figure out the doses.”

  8:18: I’m ready. I think.

  8:21: The pharmacist, trauma surgeons, and neurosurgeon have all arrived. We all lounge around the doorway, looking down the hall for the paramedics.

  8:22: “Rescue Twenty-eight in the parking lot with a code three,” blurts the loudspeaker. I run to my spot at the head of the gurney and double-check all my equipment. My palms are sweating.

  8:23: The paramedics wheel their gurney into the room, talking as they come and holding IV bags up in the air.

  “She needs to be intubated,” I hear one of them say. And indeed it is true. The child is breathing on her own, but her breathing sounds gasping and ragged. Each time she exhales she moans, an eerie, high-pitched moan, like a hurt animal; the same with each breath. She is unresponsive to stimuli. We transfer her to our gurney and everyone gathers around in the intimate frenzy of accomplishing our individual tasks. The X-ray techs are pushing people out of the way to get a chest X ray, while the trauma techs strip off her clothes, the surgeons feel her belly, and the nurses try to start additional IVs. The respiratory tech places oxygen on her to get as much as possible into her lungs before intubation. The pharmacist and the senior resident have agreed on the doses of medicines needed to sedate and paralyze her so that I can intubate her, and they signal a nurse to begin injecting the drugs.

  I don’t have much time. My heart is racing. I check her pupils: fixed and dilated. I look in her ears: no blood. I feel her bloody head for hematomas and instantly get a sickening feeling in the pit of my stomach—her entire skull is unstable. Even the slightest pressure on part of it results in clicking bone fragments and the squish of soft tissue against my other hand on the opposite side. Her left cheek is swollen and purple; there is probably a facial fracture as well. I call out my findings.

  8:25: The drugs are beginning to work. The child gradually becomes flaccid, her teeth unclench, and she stops breathing. The cervical collar has been opened in front, and the respiratory tech puts pressure on the child’s cricoid cartilage in her throat to keep the esophagus closed, preventing stomach contents from refluxing into her airway. The senior resident stabilizes her head for me, and I open her mouth and insert the laryngoscope.

  My first view is of blood and saliva; I can’t see anything that I need to see. Adrenaline and terror surge through my body. “Suction!”

  Someone hands it to me, and the blood swooshes up into the plastic tube. I push the laryngoscope in a bit further and finally see the diamond of her little white vocal cords, like broken toothpicks guarding the blackness of her trachea.

  “Tube!” Again it is handed to me, and I guide it into her trachea, never once taking my eyes off those vocal cords. “It’s in!”

  My left hand is clutching the tube at her lips for dear life. I pull the stylet out of the tube. The tech attaches a bag and begins hyperventilating the patient to reduce the swelling in her brain. The senior resident listens for breath sounds in the chest to confirm that the tube is in the right place.

  8:35: The tube has been secured with tape and the child is hooked up to a ventilator. O-negative blood has arrived and is hung. A catheter has been placed in the child’s urethra to drain her bladder. I snake an orogastric tube into her mouth, past the endotracheal tube and into her esophagus to empty out her stomach. The surgeons are worried, because the child’s belly is firm and slightly distended. The neurosurgeon would like to get a CT scan of her head, but the trauma surgeons suspect they’ll have to explore her belly in the operating room first. They are arguing politely. The senior resident is looking at X rays of the chest, pelvis, and cervical spine as they come out of the developer.

  8:42: A second hematocrit comes back significantly lower than the first. Even though the patient’s blood pressure is stable, everyone agrees she must be bleeding into her belly and needs to go to the OR. We begin “packaging” her—transferring the IV bags, monitors, oxygen, etc. to the gurney for transport.

  8:50: The patient is wheeled out of the room with the surgeons at her side, leaving miscellaneous trash in her wake. The floor is strewn with needle caps, IV bag wrappers, gauze pads, and small pools of blood.

  8:51: I go see a new patient.

  10:23: The charge nurse has heard through the grapevine that the child had a double operation: The surgeons opened her belly while the neurosurgeons put a tube into the ventricles of her brain to relieve the pressure there. When they got chunks of brain matter back through the tubes instead of clear cerebrospinal fluid, they knew her brain was hopelessly damaged. The surgeons closed her belly back up without trying to find the bleeding site. The parents saw her for the first time in the recovery room and agreed to have her removed from life support.

  11:45: I am writing up another patient’s chart when I find a loose computer label with the child’s name on it lying on the counter. Under her name is a ten-digit hospital number and her birth date.

  My eyes fill with tears and my throat begins to burn. I go to the computer room to make an entry into the procedure log.

  11:50: When I c
ome out five minutes later, I am more composed.

  VALERIE NORTON, M.D.

  Los Angeles, California

  MULTITRAUMA

  I know you are coming.

  The voice over the airways warns me.

  A voice which shares so much more

  than facts and vital signs

  (it tries not to).

  Panic, fear, anger, frustration

  overpower the static

  and tear across the miles to my ears.

  You are coming, the voice says,

  and you are dying.

  Preparation by rote.

  Multitrauma coming.

  Open fractures, sucking chest wound, bad head.

  Pedestrian, kid on a bike, no helmet.

  Hit head-on by a car.

  How old?

  Maybe ten or eleven.

  Force out the image that forms.

  How far out?

  Five minutes, no more.

  I stand and wait quietly among assembled colleagues

  and glistening instruments of resuscitation.

  Arms folded, head slightly bowed,

  eyes focused on the gray tiled floor.

  I experience a strange detachment

  from the activity taking place around me.

  The trauma team.

  Nurses focus on readying infusion sets and cut-down trays.

  Technicians discuss the never-ending business of their day.

  Residents, looking dog-tired,

  gown up in silence, pulling on gloves and adjusting goggles.

  Medical students and junior residents,

  wanting to appear in control,

  are betrayed by body language

  and pressured whispers.

  Their affected indifference only emphasizes

  their not so hidden emotions.

  I am moved by this assemblage.

  But I fear that no matter how well prepared,

  we will not be able to save you.

  “Patient in the trauma room.”

  The matter-of-fact, unemotional overhead speaker voice

  announces your arrival.

  Worse than expected.

  Intubated, CPR in progress.

  Long board, collar, sandbags, two lines running.

  Well packaged.

  Paramedics sweat from their efforts,

  their eyes and voices telegraphing

  their disappointment and stress.

  The ABCs of trauma care are welcome friends.

  I immerse myself in the ritual

  of this incredible process.

  Protect the spine.

  Secure the airway.

  Central lines.

  O-negative blood stat.

  Crystalloid challenge through fluid warmers.

  Emergent thoracotomy.

  Cross-clamp the aorta.

  Open-chest cardiac compressions.

  We perform your last rites

  in our way.

  When it is over

  and there are no more tasks to perform,

  no more traditions to uphold,

  no more heroics to attempt,

  your humanness

  and the tragedy of your death

  force their way back into my thoughts.

  For the first time I see you,

  not as another victim of blunt vehicular trauma,

  but as a child.

  Fine features.

  Sun-bleached hair.

  The smooth, unblemished skin of youth.

  Lean, muscular, an athlete’s build.

  Two colorful braided friendship bracelets

  tied about your left wrist.

  A handsome boy.

  We quietly and gently clean your body

  and prepare the room,

  absorbed in our own thoughts of

  personal mourning.

  Your parents are nearby

  expecting news of a miracle.

  I am unable to comprehend the devastation

  my visit will bring them.

  I will share my own sorrow,

  offer an embrace of understanding,

  and be there to answer questions of Why?

  and assuage guilt.

  As I cross the hall to the grieving room,

  I am again awed by the profundity

  of this very precious responsibility:

  bringing the message

  of sudden and tragic loss

  to those who must carry on.

  I count myself among the survivors,

  forever changed in some immeasurable way

  by each untimely death I witness.

  So much injury to the flesh.

  So much injury to the spirit.

  Multitrauma.

  GEORGE L. HIGGINS III, M.D.

  Cape Elizabeth, Maine

  EPILOGUE

  I looked at the doors today. They were quiet, closed. Resting. Waiting.

  Earlier this morning they had brought in a ninety-two-year-old man. As he lay on the gurney, looking up at the ceiling in the glare of the treatment room, it suddenly occurred to me that someday this would be my son. My father would be a slight memory to him. I myself would be long dead. There would be grandchildren he’d played with that I knew nothing about.

  The doors will have brought him in on this final occasion to the people inside. What will they know of him, those people caring for him on that distant day? Will they see in that old man’s face any of the young boy that I look at now? Will they know that he was once wildly cherished and that every single day he was in someone’s most tender thoughts?

  They won’t know that. And he won’t need them to know that. What will he need, I wondered?

  Just their kind presence.

  THE VOCABULARY OF THE ER

  The following is a collection of words used in the emergency room. Some are simply medical terms that appear in the stories and might be helpful to have defined. But they are interwoven with the slang of emergency medicine—words and phrases that do not appear in the text or in any medical text whatsoever. The slang is included for your information and perhaps your amusement. Some of the language may seem degrading if not outright nasty. In that respect it reflects the ongoing process of using humor or sarcasm to blunt the emotional impact of working in the Pit.

  AGONAL: Just before or accompanying death, as in: “The heart was in an AGONAL rhythm.”

  AMBU BAG: Device used to ventilate a patient who is not breathing. See BAG.

  ANEURYSM: An abnormal and dangerous ballooning out of a vessel, especially an artery.

  ARREST: See CARDIAC ARREST.

  ARTERIAL LINE: An IV inserted into an artery rather than a vein for the purpose of continuous monitoring of blood pressure.

  ASYSTOLIC: Without a heartbeat. See FULL ARREST.

  ATTENDINGS: Full-fledged doctors who, after training, teach in Emergency Departments that train new doctors. (Often referred to as “offendings” by the HOUSE STAFF.)

  BAG: To ventilate a patient with an AMBU BAG.

  BLADE: A nickname for a surgeon. Surgeons are known to be bold and arrogant—often wrong but never in doubt.

  BLEEDING ALWAYS STOPS: Need we say more?

  BOXED: Put in a pine box (i.e., died).

  BUG JUICE: Intravenous antibiotics.

  C-SPINE: The cervical spine (the neck bones).

  CARDIAC ARREST: When a heart stops pumping—i.e., the patient has dropped dead. Also ARREST; FULL ARREST. See also CODE; CODE BLUE.

  CAROTID ARTERIES: The two big arteries supplying blood to the brain.

  CAT SCAN: Computerized axial tomography. A fancy X ray that shows the inside of the body. Also CT SCAN.

  CHANDELIER SIGN: In the diagnosis of PID during the pelvic exam movement of the cervix produces pain so severe that the patient has to be scraped off the chandelier.

  CHARTOMEGALY: From “chart,” referring to the medical record, and “megaly,” meaning large or exaggerated in size. Refers to the chart of a patient w
ho comes to the hospital very frequently or is a FREQUENT FLYER.

  CHF: Congestive heart failure. When a heart gets weak and sick, it can’t pump blood very well, hence the blood does not circulate well and the blood pressure drops. In addition, the blood returning from the lungs to the weak heart tends to back up into the lungs, making the patient very short of breath. When the blood pressure drops and the lungs fill up with fluid, the patient is called SICK. Expect a CODE BLUE.

  CODE: To go into CARDIAC ARREST.

  CODE BLUE: Announced with a specific location, it means someone has gone into CARDIAC ARREST and needs resuscitation STAT.

  CPR: Cardiopulmonary resuscitation—the practice of squashing dead people’s chests in hopes of squeezing enough blood to the brain to keep them alive for a few more minutes until help arrives.

  CRACK THE CHEST: To open the chest in order to stop massive bleeding or perform open-heart massage. See THORACOTOMY.

  CRASH: When a SICK patient turns bad and starts to die. See DUMP.

  CROCK: A malingering patient with bogus complaints, as in, “Every time the train goes by, my feet get numb.” Order a STAT PORCELAIN LEVEL.

  CT: See CAT SCAN.

  CTD: Circling The Drain. A very SICK patient not doing very well. See also FTD; PBAB; STBD.

  CUTDOWN: When it is impossible to successfully stick an IV through the skin and into the vein, it becomes necessary to cut open the skin and dig down to the vein.