Respectful Insolence

Here’s a feature I’ve been meaning to start almost since I started this blog, a series along the line of Dr. Bard Parker’s Tales of the Trauma Service. Oddly enough, it only took me over a year and a half to get around to writing the first entry, for reasons that, quite frankly, I don’t know. It just sort of got away from me. (And, believe it or not, there is at least one more series idea I’ve had floating around just as long.) It’s not scientific, but it is medical, and in particular surgical.

I don’t recall if I have mentioned this before on the blog, but for about two and a half years when I was doing my graduate work in the laboratory back in the early 1990′s, I moonlighted as a flight physician with a helicopter medical transport service. This is probably about the most interesting thing about my life, and it never fails to cause listeners’ ears to perk up when I mention my brief time trying to make like Tom Cruise in Top Gun (you know, before he went all mental on us) and swooping in to rescue patients. Of course, the actual experience wasn’t exactly like that (although most of the helicopter pilots were ex-military, some with combat experience in Vietnam, and, on occasions when we had to go out for public relations runs (kids just love checking out a real helicopter), they would be sure to do an impressive swoop over the crowd both before landing and after taking off but before leaving, a maneuver which had a tendency to cause my face to turn a most sickly shade of green. Most unlike a fighter pilot.

But in reality, this job was usually 90% boredom (sitting around the call room waiting for calls, often killing time reading journals or playing around on Usenet–believe it or not, this was before Netscape and before the wide availability of access to the web), 8-9% drudgery (routine runs transporting patients who weren’t unstable, runs that made me feel more than anything else like a glorified babysitter in a flight suit), and 1-2% sheer terror. Let me tell you docs out there: You haven’t lived until you’ve tried to do chest compressions in a cramped helicopter in the middle of flight on a windy day, just you and the flight nurse, without the usual crowd of helpers that descend upon codes in the hospital, to the point where on occasion I’ve had to kick some of them out of the patient’s room. Shifts were typically 12 hours long, and, because I was the moonlighter, I usually got the night shifts. The level of activity ranged from not getting a single call (and, bliss of bliss, getting to sleep all night) to going on a run shortly after arriving for my shift, going on run after run without making it back to base until quitting time or even later. The worst runs of all, the ones that I always dreaded, usually came in near the end of a shift, at 5 or 6 AM. They were almost always very bad, and not just because they’d guarantee that I wouldn’t be getting off work on time.

This run was definitely that.

It was early on a Monday morning in late summe, a day not unlike today in fact. I hated doing Sunday night shifts, mainly because right after finishing the shift I’d have to go straight to the lab and work another 12 hours or more with no break. This was long before the days of 80 hour work weeks. Indeed, residents in the lab at my institution aren’t allowed to moonlight. In some ways, that’s a good thing, in that it forces them to concentrate on their lab work, but in other ways it’s not so good. I learned things going out on helicopter runs that I’d never have learned otherwise. I also learned things about myself that surprised me, not the least of which was the very fact that I actually could do the job, something I doubted when I first signed up to do it because it was the thing that nearly all the surgery residents did when they were in their lab years. There had only been one run that shift. Fortunately, it had been a routine cardiac run. We had picked up the patient at a small community hospital and transported him to the cardiac Mecca down the street from the hospital that was home base to my residency program, deposited him safely in the CCU, and headed back without incident. I had plopped down on the less-than-plush bed in the physician’s call room and promptly started sawing logs.

Only to have my blissful sleep shattered by the shriek of my pager. I fumbled for my glasses and looked at the clock. 5:30 AM. Shit. That means I’ll be late getting back. I grabbed my bag and hat and stumbled out the door to be met by my nurse, the pilot, and his copilot, all of whom were making their shambling way towards the helipad. We all got in, and soon the engine fired up, the rotors started spinning, and the bird started to shudder as it strained against gravity. Over my headphones, report was coming in. Apparently this was a single car MVA (motor vehicle accident), with a single victim, a young female, who was reportedly unconscious at the scene. That’s all we knew as we roared off into the pinkness of the just pre-dawn sky. In the back of my mind, I thought about my fellow residents back at the County Hospital and how grateful they would be for my bringing them a new customer right before their shift change at 7 AM. (There were two trauma teams, and switchover time between the two of them was 7 AM; again, this is before the days of the 80 hour work week. When we did trauma, we did 24 hours on, 24 hours off, for up to two months at a time. And it wasn’t exactly 24 hour on, but more like 30, because we had to round and make sure all our patients were tucked in before we could leave for the day, and once a week there was a 4 PM conference that we were expected to stick around for.)

As we circled the site, which was a parking lot near the two lane road on which the crash had occurred, we learned more. Apparently, the car had gone off the road and hit a tree at high speed. Usually, given the time of day, this means the driver had fallen asleep at the wheel. We also learned that her blood pressure was very low, and she was unresponsive. All exhaustion left me. In fact, I was keyed up so high that I had to briefly talk myself down and remind myself that my being that nervous would do no one any good, least of whom the patient. The entire flight took less than 10 minutes, as we were not far from the scene, and I knew from experience that it would probably take about 10 minutes to get back to the County Hospital, the regional Level I trauma center.

The helicopter landed on a section of the parking lot that EMS had marked off. We were out before the rotors stopped spinning, heads held low as we ran awkwardly towards the ambulance, the wind pushing down on us hard. EMS pointed to the ambulance, meaning that they had already gotten the patient into the ambulance and were working on her there. We headed that way. Out of the corner of my eye, I saw the car, a small vehicle that I could not identify, so twisted it was against a tree.

We arrived.

There, in the back of the ambulance, two EMS workers were a blur of action. I looked at the monitor. Not good. BP 70/40, pulse 120. Two large bore IVs were in and fluid was pouring in. One of the workers was at the head, trying to intubate the girl, who had been immobilized on a backboard with a cervical spine collar and whose face was covered with blood from an enormous scalp laceration. Her clothes had been partially cut away to allow the placement of EKG leads and a blood pressure cuff.

“I haven’t been able to get it,” he informed me.

“Let me try,” I said, and jumped into the back of the ambulance, not feeling at all confident in my ability to do an intubation under such conditions. Around there, most paramedics in units trained to do it were pretty good at intubating, and if they couldn’t get it I had serious doubts that I could do it. I sincerely hoped that I wasn’t forced to do a surgical airway (cricothyroidotomy. Fortunately, they were still able to bag her, and her oxygenation was acceptable.

I could see why he was having problems. She had swallowed a lot of blood and had facial fractures, and the suction wasn’t working well. I swallowed, grabbed the laryngoscope, and gave it a go, while my nurse did her assessment.

“Crepitus on the right, muliple rib fractures. Heart sounds weak. Breath sounds decreased on the right.”

Even as I was working to secure an airway I instructed her to get a chest tube setup ready. Given the blood pressure, though, I realized that the patient might be better served by us just getting her intubated and getting her on the helicopter, our version of a “scoop and run.” Putting a chest tube in in the helicopter to drain the blood and reexpand her lung would be a pain, but if she was bleeding from other sites the delay to get the chest tube in could mean the difference between life and death.

Under ideal circumstances, intubation is not that difficult. You take the laryngoscope and gently lift the base of the tongue and epiglottis to reveal under the light of the scope the vocal cords, doing so without cranking on the teeth. When you see the vocal cords, you take the endotracheal tube and put it right between them into the windpipe and then gently blow up the balloon to seal the space between the tube and the wall of the trachea. Under conditions like these, where you can’t bend the neck for fear of causing paralysis if there’s a cervical spine injury, there’s blood all over the place pooling in the back of the mouth, and space is limited, intubation can be a major challenge.

Fortunately, and much to my relief, this time it was a challenge that I was up to. I had had my doubts.

Once it was clear that the tube was in the right place and that we were able to ventilate the patient, I decided that we should get her on the helicopter. We were gathering our supplies and preparing to move her when it happened.

“Doc,” one of the paramedics said. “I can’t get a pulse or blood pressure.”

We all looked at the monitor in unison. No rhythm. Shit.

We began chest compressions, and one of the paramedics charged up the defibrillator while another one quickly cut what clothing remained covering her torso and placed conductive pads on her chest. I grabbed the paddles.

“Clear!” Everyone moved back momentarily.

Electricity caused the girl’s body to shudder, as if she were plunging her chest at the life-giving electricity.

Still no rhythm. I turned up the juice slightly according to ACLS protocol and charged up the paddles again. Shock. Still no rhythm. I did it a third time. Nothing. Double shit.

We began chest compressions again and continued the ACLS algorithm, administering drugs sequentially, followed by shocks. I plunged a 14-gauge IV catheter into the right side of her chest in case she had a tension pneumothorax from all of her rib fractures. There was no rush of air and no change in her vital signs (or lack thereof). We kept working, with chest compressions, interrupted by the administration of drugs and shocks. We ran to the helicopter, doing chest compressions all the way. A cardiac arrest after blunt trauma is almost not a survivable event. Even for a witnessed arrest after blunt trauma, the odds of reversing it and saving the patient are very small. We had to try, and, believe me, try we did, but none of us had any illusions about our chances for success, as the helicopter took off. Even so, getting her to the hospital was the only hope she had of survival, no matter how slim. We continued CPR and the complete ATLS protocol the entire way to the hospital.

When we arrived, we did a rare hot unload (usually we waited for the helicopter rotors to come to a complete stop before unloading) and moved to the elevator, one of the nurses standing on the bottom part of the gurney continuing chest compressions, and straight to the trauma bay, where the assembled team was waiting to pounce.

“How long has she been down?”

“Twenty minutes.”

The trauma team took over, and I became mostly a bystander, pushed to the side and no longer needed, having discharged my function. Discarded. I was used to it, though. After all, my function was to get the patient to the hospital in as good a shape as I could, after which all that was left was some quick paperwork and then back to the base or on another run. I moved to a counter where I could work on my paperwork and still see what was going on in the trauma bay. (Even the worst human disasters that I saw and transported had to be reported dispassionately on the same form every time.) Meanwhile, a whirlwind of activity swirled about the patient, with shouted instructions rising above the fray every so often. They worked another 20 minutes with no success. 40 minutes without rhythm, even with effective CPR, was hopeless. It was time. Her pupils were fixed and dilated.

“Call it,” the E.R. attending said to the trauma chief resident.

“Time?”

“6:40 AM.”

The crowd that had been either helping or watching dissolved away, leaving only the girl, blood and discarded wrappings strewn about, and the nurses who had the unpleasant job of cleaning up the body and preparing her for the morgue. It became very quiet. The housekeeping staff moved in to begin to clean up, to make the trauma bay ready for its next occupant, whose outcome, we all hoped, would not be so tragic. I watched as they worked. The girl was so young, no older than college age if that, and so still, the endotracheal tube protruding from her mouth, no longer hooked up to anything. Only just now I could perceive that, even with the trauma suffered, she was pretty. Her blood alcohol level had been reported as zero; so this wasn’t a case of her having been out partying all night and then cracking up her car. As I later learned from a nurse who had called her parents to come to the hospital while the trauma team had still been working on her, she had been on her way to work at her summer job at a campground. She had been going to start college in a mere few weeks. I wondered if she had brothers and sisters. A boyfriend, too, maybe. If not for one moment of weariness, she had every reason to anticipate a long life, complete with a fulfilling career, marriage, and children.

No more. The universe is certainly a cold, uncaring place at times.

It was a hell of a way to start the week. But at least I knew I would be going home later. And my wife would be there. After we got back to base, I loaded up on coffee before daring to get into my car to drive to the lab. No one asked why I was so untalkative that day.

Comments

  1. #1 Sid Schwab
    August 14, 2006

    Good story, good telling of it. I think it’s good to write such things for the public to see.
    I rode a couple of those chopper-evac flights in Vietnam. An added dimension, to be sure, but no more dramatic, really.

    As surgeons we are optimists: if we begin a thing, we assume at some level we’ll be able to finish it in a positive way. Trauma — massive trauma — seems different: we start with nothing to see if there’s a chance we can change the odds. Very often, we can’t.

  2. #2 frumious b
    August 14, 2006

    If not for one moment of weariness, she had every reason to anticipate a long life, complete with a fulfilling career, marriage, and children.

    After we got back to base, I loaded up on coffee before daring to get into my car to drive to the lab.

    I don’t blame Orac for driving, but I am concerned about a system which forces medical practitioners to be vulnerable to moments of weariness.

  3. #3 TheProbe
    August 14, 2006

    I used to commute to work by helicopter. Of course, we did not land in such welcoming surroundings. Most times, we did not land at all. If you had kept at it long enough, that wonderful stomach feeling would have turned to feelings of joy and elation over helping people. Vietnam CURED my motion sickness. However, I still do not ride rollercoasters.

  4. #4 Jon Mikel, M.D.
    August 14, 2006

    Nice storie, Orac!!

    Have you seen my video? Its lots of fun

  5. #5 That Girl
    August 15, 2006

    Its amazing how many people die every day in car accidents.

    Remember when your stuck in rush hour traffic that people rarely die during rush hour – beofre and after but rarely during – everyone’s going too slow then.

  6. #6 valhar2000
    August 16, 2006

    This brings to mind (among other things) all those movies in which the doctors give up after one minute (except for the one maverick good-looker who wants to keep going), when in real life they keep at it for almost an hour.

    We are getting used to things like these, but the truth is that the work doctors do (even those who do not face anything more life-threatening than a cold) is trully staggering in its importance. Doctors DO have the right to have a God complex, much more so than would any of the postulated gods.

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