At the time it sounded like a good idea.
It’ll be fun, my friend said. And it will be a great experience, he followed.
I was two weeks into my first year as a medical student, and Ron convinced me that I should sign up for a trauma elective. He high-fived me as we completed the paperwork, both of us displaying the cocky bravado and “I’m awesome” mentality of first-year medical students.
In the 80s the first two years of medical school was a didactic, lecture-based educational system with little to no actual clinical exposure. Day after day of slide shows and book-based study was the norm. It wasn’t until third year when students would begin to see patients through various clinical rotations.
Kings County Hospital and Downstate Medical Center were well-known for their top-notch trauma services. It was a progressive program and it gave first year medical students the opportunity to sign up for an elective in which they would spend the night with the trauma residents in the emergency department. The ROE for the elective were that the students were there to observe and gain exposure to live trauma cases in the emergency department and learn from the resident physicians. They were not to be involved in patient care.
It'll be fun, Ron said. Sign up with me. So I did.
And I had the first shift.
Two weeks after orientation to medical school I was walking through the trauma bay doors at Kings County Hospital. After shuffling aimlessly around and finding no help from the disinterested nurses staffing the emergency department, I wandered into the trauma room and found two surgical residents – equally disinterested in me - sitting on a gurney, and I introduced myself to them. I endured a few seconds of their blank stares before one of them spit his chaw into a Styrofoam cup and asked me what the fuck I was wearing.
As a 30 year veteran of inpatient medical care, it is hard for me to believe that I showed up that night wearing slacks, a dress shirt and dress shoes. I have spent the majority of my professional career wearing glorified pajamas i.e., hospital scrubs of various colors. But it wasn’t until I started my clinical clerkships that I ever owned a pair of scrubs, and it has been a part of my dress code since 1990.
Follow me, he muttered, and I trailed him into the men’s locker room where he gestured towards a stack of paper scrubs that were designed to be worn over your clothes. I sheepishly pulled them on, followed by paper shoe covers and a bouffant cap, and walked back into the trauma room feeling like an idiot.
I sat on a plastic chair in the corner and flipped through a medical journal, trying to look smart and more importantly, trying to look like I belonged, despite my ridiculous outfit. The residents – they ignored me. They showed no interest in who I was or why I was there, neither of them asking my name or asking me to produce any proof that I was supposed to be there. A few hours into the night neither of them said a word to me.
So it was a complete shock when one of them yelled for me to get the fuck up and put on some gloves. He yanked me over towards the head of an empty gurney where EMS dumped a motionless body after bursting in through the trauma bay doors.
I had never seen a patient in my life. In high school I volunteered at a local hospital but all I ever did was refill water pitchers and clean up food trays. It was an unfulfilling activity, one that almost dissuaded me from pursuing a medical career and turning instead towards a life in journalism or marine biology. I often daydream of my potential alternate life, one with days filled with typing on my laptop and scuba diving. But here I was four years later, barely two weeks into medical school, and I was literally face-to-face with my first patient.
His eyes were wide yet unseeing. He had a tube sticking out of his mouth and it was connected to what looked like a blue egg-shaped bag. The resident grabbed my hands and put them around the bag.
Every time you take a breath squeeze this bag, he said.
Despite the predetermined ROE, I did was I was told and squeezed with each of my quickening breaths.
That’s when I first noticed what was going on.
Over the years I have gained and maintained a certain degree of situational awareness, and I am able to process information despite the chaos that ensues in a medical emergency.
I did not have that ability that night.
I looked down at this man’s unseeing eyes that seemed to be staring right at me. He was not blinking and in many ways he looked like a doll. A doll with a tube in its mouth. A tube connected to a bag. I took a breath, and I squeezed.
As I forced air into his lungs, some of his brains came pouring out the bullet hole on the side of his head.
I was struck with both grotesque and dissociated fascination. I squeezed the bag again and more liquid brain bubbled from the cavity in his head. The residents were busy working on the rest of him, but I was too engrossed in the gray matter pooling on the pillow to notice when they stopped CPR and pronounced this man dead.
I kept squeezing until I heard laughter.
He’s dead, man. The resident said. I looked up and watched as he made a slashing motion across his own neck. You can stop bagging, he snickered.
I took off my gloves and retreated to my corner of the room. I picked up my journal but made little effort to pretend that I was reading. My first patient in my medical career was a dead patient, I reflected. Seemingly in response to these thoughts, one of the residents said that the patient was long dead before he came in. I suppose that was an effort to comfort the obviously overwhelmed, pale stranger dressed in paper sitting on a plastic chair in the corner. It didn’t work. And it didn’t prepare me for my second patient.
This one, however, was brought in screaming.
No brain leaking from his head, I noticed. After he was placed on the gurney his screaming suddenly stopped. One of the residents shoved me out of the way and put a tube into his mouth. The other cut off the patient’s clothes and ran his hands up and down the patient’s body, stopping at his chest.
We have to crack him, I thought I heard him yell.
I know what happened next but I actually have no recollection of it. My next memory was one where my right hand was squeezing the big blue egg and my left hand was in this man’s chest squeezing his heart.
Again, I heard laughter. He’s dead man, you can stop.
I retreated to the bathroom where I thought I was going to puke but I didn’t. My reflection, however, looked like it had been throwing up for hours.
I stared into my bloodshot, almost sallow eyes and realized with grim awareness that the second patient of my medical career died in front of me.
After the shock of the first two, I was afraid to see my third patient.
He came in after a drug deal went bad. Apparently reneging on his end of an agreement, he retreated backwards, tripped and fell on his back as his business associate fired his first shot.
The bullet penetrated the bottom of this man’s scrotum before ricocheting around his abdominal cavity. When a peritoneal lavage demonstrated bleeding in his belly, he was whisked off to the operating room escorted by one of the residents.
By now it was around 3am, and I was left alone with the other resident. I still don’t know his name, and he never asked me mine. But when the din of the ER died down a little, he pulled up a chair next to me and asked “Are you okay, man?” I nodded and he stood up with a squeeze on my shoulder.
When the next few patients came in – most of whom were significantly more stable and less emergent – he took the time to show me how to do procedures. He showed me anatomy. He explained things. And I saw how he spoke to patients and their families with compassion and kindness. There was a moment when we had no patients and he left silently, returning a few minutes later with cups of coffee for both of us.
The predawn hours brought with it a wave of new traumas. Gunshots, stab wounds, car accidents – each case unique but every one of them leaving me overwhelmed and panicked. But I watched the resident, unfazed and focused, treating all of these patients confidently and authoritatively. He was still doing so when six a.m. rolled around, marking the end of my shift.
As I was tearing off my paper coverings getting ready to leave, the other resident came back from the operating room.
That dude will be fine, he told me. And then he asked me if I was okay. Again I nodded, and he left to speak to the patient’s family.
I walked out of the trauma room, looking forward to both my dormitory bed and my next night there. I turned to wave back at the residents and looked at the sign above the doors as they swung shut.
Trauma One.
How fitting.
My first night with any clinical experience. And my first traumatic one.
It took an hour for my hands to stop trembling when I got back to my room. It took a couple of hours for my mind to stop racing , and several more before I could fall asleep.
But it took years for me to realize the impact of that night.
I have a reputation of being non-excitable in emergency situations. In an arrest, trauma or code, I tend to be overwhelmingly unruffled and on one occasion later on in my training I was accused of being “unenthusiastic” by a senior physician. During my critical care fellowship in Chicago a patient suffered a cardiac arrest in the early morning. We began CPR and started down the path of the resuscitation protocol. While the resident was performing chest compressions, the respiratory therapist was performing ventilations, and after the nurse administered the appropriate medications, there was a two-minute period before the next pulse check where I stood – motionless – running through possible causes for this patient’s arrest and preparing for the next round of interventions. I was doing what I was supposed to be doing during an arrest and what I had done during countless arrests prior to this. That is, I was thinking.
My attending – who walked in during my thinking period – did not agree and flipped out, immediately screaming for more help and activating code alarms. He threw off his white coat and rushed to the patient’s side, preparing to perform CPR ahead of the other people already in line to do so, when the patient’s pulse suddenly returned.
As I expected it to.
For the crime of failure to incite mass hysteria during a medical emergency I was written up by my attending. And to this day I remain unapologetic for my apparent apathy. That patient, by the way, did just fine.
There are an awful lot of misperceptions in Medicine, as there are in life.
Cockiness does not equal confidence.
Bravado does not equal bravery.
Quiet does not equal disinterest.
Calm does not equal apathy.
And years of education can’t replace the lessons learned that first night in Trauma One.
Perceptions aren’t important. Actions are.
And sometimes it pays to just show up. Even if you look like an idiot.
Thanks, Ron.
Comments