My first day as a surgery intern

Virtually every medical school graduate immediately enters at least three years of post-graduate medical training (internship-residency). The exceptions are those who:

1. combine the MD with a JD or PhD;

2. leverage the not-yet-dry diploma into a post as health policy advisor to a state or federal legislator, usually one of Dad’s chums;

3. are named Michael Crichton.

Commencement is in late spring, so post-graduate training begins on July 1. Every year my surgery program held a welcome/orientation breakfast for all faculty, interns, and residents.

My first post-graduate assignment that July was the Emergency Department of the county hospital. Midway from the buffet line to my seat, I was approached by the Surgery Director of the ED, his hand extended: “Congratulations!”

I started in with the usual gush, just a privilege to be part of The Program , etc., and he cut me off.

“You don’t understand. The Fire Department went on strike early this morning.”
Blink.

“The Fire Department provides the ambulances, the drivers, the EMT’s and the paramedics for all emergency calls inside the city limits.”
Blink. Blink.

“Before they went out, the strikers sabotaged all but four ambulances. Each of those remaining will be stationed at one of four hospitals. We have one. We’re responsible for all calls inside the beltway.”
Stare.

“The Red Cross is providing us with qualified drivers, but they are not EMT’s or paramedics and can do nothing to or for the patient except transportation. That’s where you come in.”

While on ED duty, until the strike ended, I was to go on every ambulance run to evaluate the patient, administer field treatment, and make the decision whether or not to take the patient to the ED.

All I could think was, “People call ambulances because they’re having a heart attack! I’m going to be a surgeon. I don’t know anything about heart attacks. Heart attacks are for internists.”

When I got to the ED, I asked my co-interns to cover my desk while I brushed up on heart attacks. I found an incredibly heavy textbook of medicine and an empty treatment bay. I was leafing through the pages, absorbing nothing, when the privacy curtain was parted by a stocky man in a Red Cross jacket.

“I’m Phil, your driver. We have a call.”

“Heart attack?”

“Head injury.”

Oh, swell. My neurosurgery rotation had been a mere two weeks and mainly about back pain. “Diuretics or not? Steroids or not? Fluids or not? Elevate or not?”

I rode right front in the swaying, wailing ambulance, frantically mining and re-mining my scanty mental archive on head trauma. The call was to one of the downtown housing projects. Phil drove over curbs and sidewalks and through several quadrangles until we found one with a small knot of onlookers.

Two residents had squabbled over rights to a particular clothesline, a squabble that ended when one hit the other with an empty beer bottle. The site of injury was just behind the left earlobe, barely an abrasion—no laceration, no bleeding, no swelling. I felt pretty silly as I performed a neurologic exam. She was mildly intoxicated but otherwise intact.

I prescribed soap and water and rest and told her to go to the ED for unusual drowsiness, severe headache, blurred vision, and any other symptom I could summon to cover my rear. I gave Phil the throat-slash “no transport” signal and got back in the ambulance.

I think when we are faced with threatening circumstances, we will take a single reassuring experience and weave it into an entire reality. At least that’s what I did. I told myself that most ambulance calls were probably as trivial as this one, and there was no point in getting worked up over it.

On our return to the ED, I noticed we had picked up a patrol car escort. A city policeman was driving, and a county sheriff’s deputy was riding shotgun.

“What’s with the police, Phil?”

“To discourage snipers.”

Great.

“Why the sheriff’s deputy, too?”

“The police are threatening to join the firefighters on strike. The deputy is there to keep an eye on the cop.”

Very great.

Back at the ED, I resumed my share of the load. Phil soon sought me out for another call: “Gunshot wound, three blocks away.”

Piece of cake. Hold pressure and speed back to the ED. There was now a definite coolness in my saunter to the ambulance.

In those days and in that program, first year post-grads wore all white: white, short-sleeved tunic, white scrub top or t-shirt, white trousers, and white shoes. Ben Casey without all the chest hair. There was quite a crowd in front of the address, spilling over the sidewalk and into the street. They parted, Cecil B. DeMille-like, as Phil and I made our way to the house. I heard murmurs of “the doctor…the doctor.”

Hardly a house, the place was a tuberculous shanty that sat immediately at the sidewalk’s edge. There was a grayed, splintered, wooden porch only two steps up, seated on the floor of which was the victim, propped against a door jamb. His eyes and his mouth were wide open, and through the latter came a pulsatile arc of bright red blood. There was no apparent entry wound.

As I was taking this in, a disembodied voice told the story. Mr. V and his pal were sharing a half-pint when a pedestrian engaged them in conversation. At some point Mr. V opened his mouth in rebuttal and the pedestrian took the opportunity to shoot him through it, hitting his carotid artery by the looks of things.

It was apparent to me that Mr. V was not only bleeding to death but drowning in his blood. An airway was the first priority, and I slid around on elbows and knees in the blood-slime to get him on his back and a tube into him.

Futile. I had no suction, no light, and no expertise. I looked at Phil and said, “Let’s take him.” We put him on the rolling stretcher and scurried to the ambulance. Someone behind us said, “He was doing fine until the doc laid him down.”

In the patient bay of the careering ambulance, I tried getting some air into him to no avail. We rolled him into the resuscitation room, where the entire surgical team was waiting in response to Phil’s radio call.

The Chief Resident in immaculate, starched, knee-length, bright-white lab coat held up his hand to stay the team from transferring Mr. V to the resuscitation table. He looked at the obviously lifeless form and at me, covered in a goodly portion of Mr. V’s blood volume. He turned back to the team, said, “Bag it,” retrieved his still-steaming cup of coffee from the scrub sink counter and went back to wherever Chief Residents come from. The rest of the team looked at me in the equivalent of a group shrug and prepared Mr. V for the morgue.

I went to the detox room. I rolled my blood-wet clothes into a sheet, washed my shoes as well as I could, and hosed myself off. The water was cold. I put on fresh scrubs, laced up my pinkish shoes, geared up with stethoscope, pen, and penlight, and went to work my desk until the next call would come.

In one of my interviews for residency, a faculty surgeon said, “The day you graduate from medical school, everyone in your family will think that you are a doctor. They will be wrong. Give us five years, and we’ll make you a real doctor.”

This was the morning of the first day.

Richard Patterson is a surgeon who blogs at DailyDudley.

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  • http://twitter.com/geekcamron Abel

    Wow

  • megan

    oh god. perfect timing.

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