It’s every emergency resident’s dream to be part of a big procedure: The rush of a heart-pounding, adrenaline-filled moment of slamming in a chest tube, “criching” someone or being part of the big show — a thoracotomy. The holy grail. Cracking a chest, performing intracardiac massage, cross-clamping the aorta. A last-ditch effort to pull a patient away from the clutches of the grim reaper. A typical level-one center hums to life when a paramedic call comes in of a penetrating trauma to the box.
Everyone and their mothers run down to the ED. There is, of course, the ED team, the trauma surgery team, pharmacists, techs, a battery of nurses and even an anesthesiologist or two may mozy on down.
It’s the middle of a busy typical county weekend night. The usual: sick medical patients getting intubated, drunks acting a fool and confused people that haven’t realized that the ER is meant for emergencies and not for a cough and cold. Suddenly the call comes in — a 24-year-old with multiple gunshot wounds. Unstable on the field. ETA five minutes. My senior resident and I run over. He sets up the airway equipment. I open a thoracotomy tray on the left and head over to the right with a chest tube tray ready for action. The page goes out. The patient arrives just before the trauma team showing up. Paramedics are bagging and performing CPR. “The patient just lost pulses,” announces the paramedic slamming on her chest wall.
The stars have aligned, and we are ready. We have the swag to own this trauma.
My baller senior resident intubates the patient in a flash and heads over to the left side to start the thoracotomy. I make my cut into the 4th intercostal space on the right. He’s in the chest, the trauma team arrives and watches him deliver the heart with ease. The left side of the chest is as dry as … I don’t know … the Mojave Desert (poetic I know). I have slammed the chest tube into the right side.
“Guys, I’m getting a ton of blood from this chest tube, I’m going to open the right side.”
I grab a scalpel and make the cut. A deep definitive cut, without hesitation. They pull out a chisel … clank clank clank. Across the sternum. I’m through the chest wall, and the entire thing pops open like a hood of a car. We find the bleeding source on the right side. We clamp the hilum; blood is being transfused, and epi is being injected directly into the left ventricle. We got a pulse. Phew. In a coordinated rush, we begin to package the patient for the OR.
Sh*t … she lost her pulse again. For that brief moment, we had her back.
More epi, more cardiac massage, more blood. We can’t get the engine to turn over. Game over. We call it. The monitors are turned off. Everything gets quiet. Everyone scurries away. I stand at the foot of the bed. Patient is filleted opened. The floor is covered in blood. Bloody towels and rags everywhere. The gravity of the situation takes hold. At first, I was excited about getting to perform a career-defining procedure. Then I realize that the situation is not about me, not about performing a procedure, but about a life. Holy crap. How did this happen?
It went from being an exciting, adrenaline rush, career-defining moment to cold hard reality. This young girl with an unknown life, unknown family, unknown future potential is gone. C’est la vie. The shift ends four hours later. I drive home. Go to my fridge. Stand with the door open so that the cold air hits my face. I remember the image at the foot of the bed. My head hangs.
The adrenaline of the night fades, and I succumb to the comfort of my bed. Game over.
Zahir Basrai is an emergency physician who blogs at the Physician Grind.
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