Making a difference

December 3, 2010

Experience with certain patients inevitably become retained as "teaching points," both positive and negative, to be tucked away for use in future patient care.

Every once in a while, we become involved in medical events that are outliers-truly extraordinary events that will never be forgotten. Two such instances happened to me back-to-back when I had only been in practice for a few months. It has been almost 3 decades since they occurred, but it might as well have been yesterday.

TEAMWORK IN THE FACE OF TRAUMA

I was gradually becoming acquainted with various members of the Lowell medical community and was learning my way around the 3 hospitals in town. When not in the office I spent most of my time at the old St. Joseph's Hospital, a fine institution and a wonderful place to work despite being a bit of an eyesore even by the standards of 1980. Indeed, virtually no one ever used the front door of the hospital. Rather, staff and patients entered and exited by the side basement entrance on Salem Street next to the garbage (and the physicians' "lounge," where the nuns made certain we always had an ample supply of coffee and donuts). Across Salem Street was the woefully inadequate hospital parking lot, and down the sidewalk to the left was a side of the emergency room entrance.

I spent a good deal of time in the EKG department on the third floor of the hospital. One afternoon, several weeks after my arrival, I was sitting in the department reading tracings when I heard over the loudspeaker, "code 99, dialysis."

"Where's dialysis?" I quickly asked the cardiology secretary.

"On the sixth floor."

Off I went like a rocket, bolting up 3 flights of stairs to the dialysis unit. I had run many codes before, so I was prepared for yet another. However, the scene that greeted me was beyond my wildest expectations. People were screaming everywhere.

The dialysis unit was basically a large square room that was clear in the center, with chairs and machines stationed around the periphery. Lying supine on the floor in the center of the room, with no one and nothing within at least 15 feet of him in any direction, was a nephrologist I barely knew.

"Bob, I've been shot. I can't feel my belly. I think he got my aorta," he said.

I found myself kneeling by his side, completely out in the open, and my first thought was that the person who shot him might not take kindly to whoever might come to help. I figured I was next and that I could be as good as dead. I called out, "Where's the gun? Where's the gun?" and then turned my attention back to my new patient, staying by him.

Of course, when a "code" is called, forces mobilize from all over the hospital. I will never know how long it took for the cavalry to arrive, but I felt as if I were a solitary shooting gallery target for at least 5 minutes. In actuality, how long could it have been?

Once the room filled with people, even though they were people I didn't yet know, I at least felt more or less safe from mortal injury.

A deranged dialysis patient had shot the nephrologist from behind. The reason my colleague couldn't feel his abdomen was because his thoracic spinal cord had been severed by the bullet. However, more was going on, as the victim's vital signs were deteriorating. An anesthesiologist whom none of us knew (he was also new to the hospital) intubated the physician as he lay on the floor. We established IV access and obtained a chest x-ray. The left hemithorax was obliterated.

We hoisted our fallen colleague onto a stretcher and wheeled him to the OR. Dr. C, a surgeon I had met once or twice, entered. I went into the OR with him, figuring that my fellowship experience in watching elective CABG and valve replacement surgery might be helpful in dealing with the first case of penetrating chest trauma I had ever seen. Dr. C didn't need any help. Unbeknownst to me, not only was he a chest surgeon, but he had previously been drafted to serve in Vietnam, where he had worked in a MASH unit.

The bullet had also severed an intercostal vessel, and the victim had a hemopneumothorax, which the surgeon rapidly diagnosed and attended. The mediastinum had somehow been spared, the bullet ending up subcutaneously in the anterior chest wall. There were no other apparent injuries.

Just after closing, our patient inexplicably went into ventricular fibrillation. I grabbed the paddles and defibrillated him. We then took him to the ICU, where one of my new partners spent a good part of the night at his bedside.

So much for being a "red hot." I had never seen anything remotely like this. I had had essentially no trauma training. I was dumbfounded, let alone speechless. All I could do was say to Dr. C, "You're my hero," as I shook his hand.

That evening I recounted all of this to my wife. Not only had the events been dramatic and not only did I have to defibrillate a colleague, but for a moment I had thought I might die as well. Not long after that, I developed a case of shingles, and I'm convinced that the emotional stress related to those events was the trigger.

What I did not know was that I was not yet done with my apprenticeship.