“Jesus Christ, take the trocar out. You shouldn’t be using it until you know what you’re doing, which probably isn’t going happen anytime soon.”
She stood on the other side of the metal procedural table that was covered with a sterile drape on which the thoracostomy tray lay open, filled with shiny instruments and blue towels. “This is the perfect patient for your first time. She’s unconscious, probably can’t feel anything, although I’m not sure about that; and, she already has her airway.” Claire watched me pull the trocar from the chest tube. I tossed it at a waste container a few feet away and managed to miss. It clattered across the floor of the trauma room. I saw a nurse roll her eyes.
“Nice,” Claire said. “Now, always make the incision at the inframammary crease between the anterior and posterior axillary lines; in front for air, and in back for blood. You don’t want to get in the muscle of the pectoralis or latissimus—it’ll just be harder.” She looks at me, “where are you going to make the incision, front or back?”
“Front. She has a tension pneumo, so it’s air.”
Although six months old, I was still far enough down the food chain that I hadn’t actually placed a chest tube yet, but I knew what to do. It wasn’t the first time I picked up a scalpel to cut a live person, but it was one of the first times and it still felt un-natural, slightly illicit, like it was a sin. Pressing the blade into the skin, I felt the dermis part, exposing the lobulated fat of the subcutaneous tissue pushing out like whitish-yellow lips lightly touching, and then the blood; always, the blood.
“Alright. Chop chop. Let’s move. Make sure you cut deep enough into the sub-Q so you can make your tract.” Claire looks over at the monitor, “pressure’s down, the needle thoracostomy isn’t enough. If you don’t get that tube in in 30 seconds I’m going to do it; or maybe I’ll have Bill do it.” She nods towards Bill, MS4, a lowly student, on the other side of the patient.
The girl on the gurney is black but not too much, maybe half-black. I think she’s pretty, but it’s hard to tell with swelling along the left side of her face from some form of blunt trauma, a C-collar in place, and blood pretty much all over from the knife wound, a gaping bloody slit, like an open mouth, at the upper outer edge of a generous breast. It started bleeding again after the occlusive dressing came off when Bill prepped the chest with a handful of 4×4’s, soaked in Betadine.
I push the curved clamp through the smaller, bloody slit I’d made, about six inches below the stab wound and a little posterior. I feel the muscle spreading on either side of the jaws of the clamp. It’s like using a scissors in reverse. As soon as I puncture the pleura a satisfying hiss of air under pressure escapes. I feel it on my face. It’s warm and humid, like a tropical breeze in Belize, salty even. I’m surprised at how easy the tube went in. Claire noticed, “It’s a lot harder when they’re fat or muscular; and actually awake.” I couldn’t tell if Bill was relieved or disappointed that I got the tube in.
“OK. Nice job.” Claire steps away. “See. Pressure’s back up. You saved another life.” Then she blinks, “Oh, it’s probably your first.” Bill looks at me now. I see envy; I guessed that he was disappointed rather than relieved. “Get her admitted. Call me if you need anything.”
Clair leaves. I tell Bill, “You do the H&P. I’ll do the orders.” The H&P takes longer, but we both know that shit flows downhill, down the hill that I climbed a year ahead of him.
I suppose that’s why I didn’t recognize her name a month later when I saw her in the surgery clinic.
Angel, birth date, 2/18/58; she was twenty-two years old, back in the days when the new millennium was far enough in the future that the year designation was marked by two numerals rather than four. The writing in the chart looked familiar, roundish letters with a backward slant specific to a left-handed writer, and then I saw Bill’s signature and the date, significant, perhaps not as much as the day Kennedy died, but almost; the date I first saved a life, even if a chief resident was at my side, telling me exactly what to do.
The patient is a 22 y.o. black female brought in by squad after sustaining a stab injury to the upper right chest secondary to an altercation with another female regarding a boyfriend, of which girl, is unclear at this time; however, the patient maintained (per documentation at the scene) that Duwayne was her boyfriend and that “that bitch” is “gonna get it. Reel bad.”
Geez, Bill. I stifle a laugh.
I enter the room after a soft knock on the exam room door, like I was taught. “Hellow, Angel,” I say.
A stunningly beautiful black woman stares back at me. She is wearing bib overalls with maybe a tank-top under, but I can’t be sure.
I struggle for words. It’s difficult to reconcile the supine, bloodied, bruised, almost dead body with this one so obviously alive, vibrant, and with a gratuitous display of side boob that is modestly difficult for my twenty-eight-year-old male mind to move beyond. Finally, I manage after what I hope was not to awkward a pause, “well, how are you doing?”
I’m pretty sure Angel knows fully well her effect on the weaker sex. “I’m doing fine, doc. Almost didn’t come in, but I wanted to say thanks, and,” she turns to the side, pulls away the top of her bib overalls exposing at least three-fourths of her right breast, “Will this scar get smaller?”
She’s talking about the knife wound. The sutures were removed before she left the hospital, but the scar was still inflamed and red. It didn’t look like keloid to me, and I told her that it should get a lot smaller and less noticeable in time. Then I talk to her about choices. I tell her that she’s a beautiful young woman and that she has much to live for and how close she came to dying that night. I tell her that she has to be careful about the friends she makes, about the people she hangs out with. I can tell it’s not working, that she’s not listening, not hearing, like I’m a nonsensical vocalization in a Peanuts cartoon going whaa, whaa,whaa. I still try.
Being a chief resident’s a lot better than being a junior one; indescribably better in fact. It’s my night on call, pretty good odds of being on call; every-other, thirty-six hours on, twelve off, better than 50%, actually 75%. I have four months before my real job starts. The trauma pager goes off, but I’m seeing a medicine consult for vascular access for dialysis and so I figure I’ll let my junior resident handle it. I trust him. He knows when to call.
“Ken. You better get down her now.” Jeff’s voice is tight, stretched thin. He’s holding his breath, talking at the point of end-inspiration. I recognize it, having done the same myself, many times. “It’s a pregnant female in the third trimester with a gunshot wound to the chest, intubated, CPR in progress but had vitals at the scene.” I hear air escaping from his lungs, like he’s coming up for air from a free-dive at depth. I can almost feel it through the ear-piece of the phone.
“I’ll be right down, Jeff. Prep the patient and open up the thoracotomy tray and have Swann introducers ready to put in. I want you to do that first thing on the opposite side while I’m doing the chest.”
Of course, it’s Angel:–the yin and the yang, the alpha and the omega, the beginning and the end. It was so poetically poignant; like it was meant to be, some lesson for which I knew not the purpose of. As I made the futile slash along the infra-mammary crease from the sternum to the table, I screamed into the room, “Where’s OB? We need a stat C-section now.”
It was a small caliber wound, but in contrast to Angel’s previous good fortune four years earlier, the entry wound bisected the left main coronary artery and apart from the bleeding from the holes in her heart, there was not enough contractility because she had suffered a heart attack from the loss of blood-flow to the left ventricle.
I had both hands in her chest, my wrists rubbing against the metal jaws of the rib-spreader. She had two large-bore IVs running wide open, and Jeff’s introducer in the right subclavian. Amazingly, I could feel the blood and fluid filling her heart, and then I’d squeeze, 100-120 times a minute. I heard a nurse say that she could feel a pulse. The OB chief was bumping up against me. A baby cried.
I looked at Angel, her eyes were open. Was she still in there…a faint light? The blood and fluid welling up out of her chest covered the bed and the floor. I was soaked in blood. It was on my face, on my glasses. I was red up to my elbows. I stopped squeezing. I was the only one who saw it. Of what, I wasn’t sure, maybe a few seconds before I stopped:–the faintest flicker of a presence, made remarkable only by its sudden absence, like a cello’s last strains of Bach’s Prelude escaping a room.
I posted a link to a chest tube insertion below. It is not my video and so the availability is subject to the producer.
These are all great stories of the stress and horror and then relief that all surgeons go through. I hope. Angel hit me particularly hard because I’ve read of such cases and felt so bad that people just can’t be reached and stay on the road to self destruction. Hippocrates, you are an angel also.
Thank you for reading, Joyce. I just now, one year, four months, seven days and seventeen hours later, read your comment. I’m a terrible blogger.