My Life as an Emergency Surgeon
By James Cole
St. Martin's Press Copyright © 2011 Dr. James Cole
All rights reserved.
The Trauma Surgeon
The stinking man's blood trailed along my arm and torso, and then ran down my leg, soaking through my scrub pants. My foot swam in a pool of the sanguineous fluid, which saturated my sock and was welling up inside my operating room shoe. The shoe — constructed of a lightweight, rubbery material that easily repelled all fluids — was keeping my patient's blood in close contact with my body as I worked. The cool, sticky sensation was terribly unpleasant, but there was nothing I could do to remedy my personal discomfort at the time.
My gloved left hand was pressed deeply into the gaping gash in the left side of my patient's neck. He had only recently been made calm, after an emergency medicine physician accommodated my request to place an endotracheal breathing tube into my patient's mouth after I ordered the senior trauma nurse to administer a hefty dose of an intravenous sedative.
Only minutes prior, I responded to a page summoning me to the trauma room. The anxious paramedics arrived with my patient at the very moment I entered the emergency room trauma area; I had no time to don any protective garments other than a pair of gloves. I had never before seen so much blood. My patient's head, face, neck, and previously white T-shirt were a bright red confluence. His arms, flailing about as paramedics kept him physically restrained to the transport gurney, were saturated with the substance. The paramedic at the head of the moving cart had blood splattered about his face as he struggled to keep the anxious and very agitated victim from rolling off the moving platform. A large pile of crimson gauze was partially secured to my patient's neck with wide swaths of blood-soaked tape, doing very little to control the ongoing exsanguination from the obvious neck injury.
I helped the four attendants move our foul-smelling patient from the paramedic gurney to the trauma cart. I leaned my face as far away as possible from the obviously intoxicated and combative individual, but I could only maintain so much distance from him with my hand firmly pressed into his neck wound. There was too much noise in the trauma room for anyone to hear my orders. Paramedics, nurses, and technicians of every variety were all speaking at anxiously loud levels, completely oblivious to all other conversations. Everyone was speaking above the other — but no one was really doing anything.
"Okay. All eyes on me!" I commanded in a firm, but nonthreatening voice. The room silenced, with the exception of the man whose neck I had in my grasp, who continued to struggle and moan in a most unpleasant manner. The stench of his filthy, inebriated body stung at my nostrils. I took a look about and realized that the volume of blood in the room had been a shocking sight to more than just myself. People all around me looked somewhat frightened. They needed direction, and they needed leadership.
I removed the bulky, ineffective dressing from my patient's neck and dark blood coughed out like water from an old pump of a country well. I placed my index and middle fingers deep within the huge, bloody wound, and I plugged the source of the hemorrhage. I could not move my hand, as it was the only thing preventing my patient from bleeding out on that trauma room table. But with my fingers in the dike, I couldn't do all else that was necessary to manage my trauma patient. I needed help from my team.
As I had done many times before, I ran the ABCs of trauma resuscitation. I ran the mental checklist as I had done repeatedly on past occasions. My patient's airway needed securing. I made eye contact with the nurse and told her to administer the intravenous sedative and paralyzing agents. I told the emergency medicine doctor rubbernecking near the foot of the bed to place the breathing tube. In less than two minutes, the airway was secured. I then asked the respiratory therapist to listen to the lungs. I watched as she nodded affirmatively as she heard breathing sounds on the left side, and then on the right side of my patient's chest. I ordered a second nurse to infuse a one-liter, intravenous bolus of fluid, and told the emergency room technician to get me a set of vitals.
"Eighty-six over fifty-four, sir, with a heart rate of one-twenty," he shouted confidently. I ordered the charge nurse to get me two units of O-negative blood and to run them in as quickly as possible. As she left the resuscitation room, I looked at the nurse who had hung the bag of intravenous (IV) fluid and asked her to call the operating room and prepare for an emergency neck exploration. She pulled a phone from her pocket and she made the call.
About five minutes later, a swarm of trauma personnel was rushing my patient into the operating room. I never left my patient's side; my fingers remained plunged deep within his anatomical defect. Once in the OR, we transferred my casualty onto the operating room table and I told one of our specialty transport paramedics to slide his fingers on top of mine. I guided his two digits into the desired position, losing another several cupfuls of blood in the process. I told him not to move a muscle, and ordered my patient's neck prepped — paramedic fingers and all — as I exited the operating room to scrub my hands.
When I returned, my patient was prepared and ready for me to definitively control the hemorrhage. I shouldered the paramedic holding pressure deep within the neck, and began my procedure. With several swipes of my scalpel and a few bold cuts with my scissors, I exposed the entire length of my patient's internal jugular vein. After instructing the paramedic to slowly move his fingers out of the wound, I witnessed the nearly transected, jagged vein spew blood at me like an erupting volcano. Recognizing the futility of attempting to repair the vein, I decided to sacrifice it. I clamped the vein above and below the devastating laceration, and the bleeding stopped. A few well-placed surgical ligatures stemmed the blood loss indefinitely, and I removed the clamps.
With the hemorrhage definitively controlled, I spent the next thirty minutes performing a thorough neck exploration in full trauma fashion. I examined my patient's carotid artery and all its branches, glad to see that the wounding instrument had narrowly missed the most important of vascular structures in the neck. A man could survive with his jugular tied off, but he could never survive if I had needed to do the same to his carotid. I then examined his trachea and his esophagus, neither of which had any evidence of injury. His thyroid gland was cut and was oozing, but a thorough cooking from careful applications of my electrocautery probe laid that problem to rest.
I concluded my operation by meticulously repairing the layers of damaged muscle my patient's neck had suffered — obviously from the sharp edge of a boldly plunged knife of a vengeful assailant. When my last skin clip had been applied, I neatly dressed the wound with gauze, I thanked the entire operating room staff for their excellent assistance, and I left the room to change out of my bloody scrubs, to cleanse my skin of the filthy patient's bodily fluids, and to seek a family member to brief of the work I had just completed. The blood clinging to the lower half of my body made me a bit nauseated, but I would soon rid myself of the semi-clotted, bloody gel.
I am only human. The other doctors, nurses, and the various health-care technicians who surround me and comprise my trauma team are also human. We are nothing special. But as the trauma surgeon in charge of a team of people, tasked by virtue of my particular job title to take control of otherwise chaotic situations — often horrible situations where death might otherwise seem inevitable — I and the other trauma surgeons who have shared my experiences are often placed in unfair situations.
When gravely injured men, women, girls, and boys are rushed into the trauma room, often by several paramedics panting to catch their breath as they sprint with their limp and bloody casualties toward the trauma beds so as to pass off a responsibility greater than they wish to be in charge of, the multiple members of the trauma team occasionally gasp. They often then take a momentary half step back and close their open, yet silent, hanging jaws, as something terribly shocking overcomes even the most grizzled and well-seasoned of the trauma groupies.
It is in one of these "Holy shit" moments that all eyes glance toward the trauma surgeon, and when the team members quietly look for a momentary sign of confidence — some nonverbal indication or cue that the trauma surgeon will be able to handle the situation in a smooth manner, regardless of whether the patient may live or die. The more seasoned ancillary veterans of the trauma team — often the charge nurse, or a graying, senior X-ray technician — know that the very worst of the worst trauma casualties may not have even the slightest chance of living beyond the confines of the trauma room. But it is often not the amount of blood soaking through the sheets and the mattress of the ambulance cart, the volume of the patient's screams or lack thereof, or even the sight of human bowel billowing out from an open body cavity, that clues those truly in the know as to the likely potential for a badly injured casualty to live another day. Instead it is that momentary look on the trauma surgeon's face that either says "Okay, bring it on," or "What the hell am I going to do with this?"
All trauma surgeons have thought or have even muttered the latter of the two statements at one time or another. After all, we are human. There is no special place in a trauma surgeon's DNA that gives us immunity to that vile feeling of impending nausea when seeing and smelling the charred flesh of a young man who has been burned to a gruesome char. There is no particular course of surgical instruction that, upon successful completion, imparts absolute fearlessness onto the surgeon's constitution. And there is no special On/Off switch that has been biologically impregnated into a trauma surgeon's soul giving him the unique ability to tune out the blood-curdling screams and the wailing of a mother who has just been given the horrifying news that her teenaged son — whom she gave birth to, whom she nursed for six months, whose diapers she changed, and whom she raised to the best of her abilities with all of the love and hope that she could muster — has just died after an unsuccessful attempt to save him from a stray bullet that tore a hole through his chest while he was mischievously hanging out with his friends.
I can't imagine that there is an honest trauma surgeon out there who has never had his "What the hell am I going to do with this" experience in his career. Fortunately, for the majority of us, we had most of those experiences during our residency training. But despite our thousands of hours of surgical indoctrination, apprenticeship, and well-intentioned brainwashing over the five or more postdoctoral residency years of our early careers, we still continue to experience all of the human emotions.
Yet, it is our responsibility to not allow that component of natural humanism to adversely impact our abilities to critically assess, resuscitate, and manage the most severely injured trauma victims. It is in those very worst of situations, when the trauma team looks at us for direction and guidance, that we must remain the "Captain of the Ship" and do our very best to project strength and confidence to our crew. It is then when it becomes most important that we maintain a quiet calm in a room filled with anxious cacophony, and when we must perform our surgical procedures with precision and smoothness despite the immeasurable levels of adrenaline that surge through our veins.
That is when I have at times felt that I was placed in an unfair situation, as if I was being held to a higher-than-human standard. Attempting to meet that standard has given me challenges which I have accepted yet many of my nonsurgeon colleagues have respectfully declined. But it has also been those challenges which have allowed me to excel at my craft, merely and solely by the will and by the grace of God.
Over the course of my twenty-year career as a physician and surgeon, I have cared for thousands of critically wounded and gravely ill individuals. I have treated patients wounded from both common mechanisms of injury, and by every other gruesome cause imaginable. I have treated gunshot wounds, stabbings, slashings, impalement injuries, industrial accidents, farm-equipment mishaps, crush injuries, and war wounds. I have seen the life pass from individuals too numerous to count — men, women, and children — as they died in my presence. And I have on countless occasions borne the unpleasant responsibility of breaking the gut-wrenching news to family members and friends — who just hours prior saw their spouses or loved ones off to work or school — that the person whom they once loved so very dearly in life, had now passed on to the world of the dead. I have heard the wailing and the screaming of grieving mothers, and I have seen the faces of the victims' fathers age before my very eyes. I have often felt that for every family to whom I have given the terrible news, I myself have sacrificed at least a few days of my own life.
Over the years I have crossed paths with presidential cabinet members, admirals and generals, executives of great stature, and the socially elite. I have also crossed paths with drug addicts, gang members and other violent criminals, the mentally unsound, and the homeless. Yet, regardless of whom I have treated as patients, whom I have worked for, and whom I have been directly influenced by, I have somehow been able to retain the understanding that everyone — some of whom present themselves covered in an attractive veneer of success and prosperity, and others literally exuding the stench of poverty and hopelessness — has the same basic wants and needs. All individuals ultimately seek a pain-free existence, compassion and understanding, and the chance to live yet another day.
There were many times in which I could manage my patients' conditions, and other times in which I couldn't. During those times in which I just couldn't resolve my patients' suffering or prolong their mortal existence any longer, I became reminded ever so bluntly that my powers as a physician are limited by something more than the constraints of just science and technology — that other factor being exponentially more powerful and unyielding than all of man's labors, inventions, and medicines combined. It has become clear to me that despite all of our efforts, we mortals are at times powerless in effecting whether one lives or dies.
Yes, I am human. I am nothing special. But my experiences have been nothing short of special, and at times spectacular. It has been those experiences that have made me the bona fide trauma surgeon that I have become.
The General Medical Officer
The Early Postgraduate Years
In July 1992, the military sentry guarding the front gate of Camp Pendleton noticed the blue Department of Defense sticker affixed to the windshield of my car, and he saluted me smartly. I drove through the main gate with my father-in-law in the seat next to me, and my pregnant wife in the back, tending to the constant needs of our one-year-old infant boy. We had just driven nearly three thousand miles, from the Atlantic coast to the Pacific coast, and we were exhausted. We had traveled on military orders as I had just one week before completed my internship at the U.S. Naval Hospital in Portsmouth, Virginia. I looked forward to my new adventure on the West Coast. Frankly, looking back, I believe that I could have easily looked forward to any adventure, opportunity, or simple break from the grueling, yearlong, postdoctoral internship I had just endured.
I was exhausted. I had been in academic overdrive for the past nine years — having spent four years earning my premedical degree, four more years earning my medical degree, and the most recent year working as a postdoctoral intern. I knew that I had at least four more years of postgraduate medical education to complete prior to earning my surgeon's wings, but I so looked forward to my next two-year educational break serving as a primary care physician assigned to a United States Marine Corps operational unit.
I spent the last two months of my internship on trauma rotations. In May, I had been assigned to the Orthopedic Trauma Service, and in June, I worked on the Trauma Surgery Service at Norfolk General Hospital — the region's only, major trauma center. I enjoyed my orthopedic trauma rotation, where I became proficient at managing various trauma-related bone and joint disorders, and where I learned the art of reducing fractured bone ends into perfect, anatomic alignment, prior to applying layers of plaster or fiberglass to immobilize the damaged extremities. I assisted on many operations, most of which involved the lower extremity. And I met some very interesting people. (Continues...)
Excerpted from Trauma by James Cole. Copyright © 2011 Dr. James Cole. Excerpted by permission of St. Martin's Press.
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