pale, blood running out of her nose. A nurse directed the crew into Trauma Bay 1, an examination room outfitted like an OR, with green tiles on the wall, monitoring devices, and space for portable X-ray equipment. We lifted her onto the bed and then went to work. One nurse began cutting off the woman’s clothes. Another took vital signs. A third inserted a large-bore intravenous line into her right arm. A surgical intern put a Foley catheter into her bladder. The emergency-medicine attending was Samuel Johns, a gaunt, Ichabod Crane–like man in his fifties. He was standing to one side with his arms crossed, observing, which was a sign that I could go ahead and take charge.
In an academic hospital, residents provide most of the “moment to moment” doctoring. Our duties depend on our level of training, but we’re never entirely on our own: there’s always an attending, who oversees our decisions. That night, since Johns was the attending and was responsible for the patient’s immediate management, I took my lead from him. At the same time, he wasn’t a surgeon, and so he relied on me for surgical expertise.
“What’s the story?” I asked.
An EMT rattled off the details: “Unidentified white female unrestrained driver in high-speed rollover. Ejected from the car.Found unresponsive to pain. Pulse a hundred, BP a hundred over sixty, breathing at thirty on her own . . .”
As he spoke, I began examining her. The first step in caring for a trauma patient is always the same. It doesn’t matter if a person has been shot eleven times or crushed by a truck or burned in a kitchen fire. The first thing you do is make sure that the patient can breathe without difficulty. This woman’s breaths were shallow and rapid. An oximeter, by means of a sensor placed on her finger, measured the oxygen saturation of her blood. The “O 2 sat” is normally more than 95 percent for a patient breathing room air. The woman was wearing a face mask with oxygen turned up full blast, and her sat was only 90 percent.
“She’s not oxygenating well,” I announced in the flattened-out, wake-me-up-when-something-interesting-happens tone that all surgeons have acquired by about three months into residency. With my fingers, I verified that there wasn’t any object in her mouth that would obstruct her airway; with a stethoscope, I confirmed that neither lung had collapsed. I got hold of a bag mask, pressed its clear facepiece over her nose and mouth, and squeezed the bellows, a kind of balloon with a one-way valve, shooting a liter of air into her with each compression. After a minute or so, her oxygen came up to a comfortable 98 percent. She obviously needed our help with breathing. “Let’s tube her,” I said. That meant putting a tube down through her vocal cords and into her trachea, which would insure a clear airway and allow for mechanical ventilation.
Johns, the attending, wanted to do the intubation. He picked up a Mac 3 laryngoscope, a standard but fairly primitive-looking L-shaped metal instrument for prying open the mouth and throat, and slipped the shoehornlike blade deep into her mouth and down to her larynx. Then he yanked the handle up toward the ceiling to pull her tongue out of the way, open her mouth and throat, and reveal the vocal cords, which sit like fleshy tent flaps at the entrance to the trachea. The patient didn’t wince or gag: she was still out cold.
“Suction!” he called. “I can’t see a thing.”
He sucked out about a cup of blood and clot. Then he picked up the endotracheal tube—a clear rubber pipe about the diameter of an index finger and three times as long—and tried to guide it between her cords. After a minute, her sat started to fall.
“You’re down to seventy percent,” a nurse announced.
Johns kept struggling with the tube, trying to push it in, but it banged vainly against the cords. The patient’s lips began to turn blue.
“Sixty percent,” the nurse said.
Johns pulled
In an academic hospital, residents provide most of the “moment to moment” doctoring. Our duties depend on our level of training, but we’re never entirely on our own: there’s always an attending, who oversees our decisions. That night, since Johns was the attending and was responsible for the patient’s immediate management, I took my lead from him. At the same time, he wasn’t a surgeon, and so he relied on me for surgical expertise.
“What’s the story?” I asked.
An EMT rattled off the details: “Unidentified white female unrestrained driver in high-speed rollover. Ejected from the car.Found unresponsive to pain. Pulse a hundred, BP a hundred over sixty, breathing at thirty on her own . . .”
As he spoke, I began examining her. The first step in caring for a trauma patient is always the same. It doesn’t matter if a person has been shot eleven times or crushed by a truck or burned in a kitchen fire. The first thing you do is make sure that the patient can breathe without difficulty. This woman’s breaths were shallow and rapid. An oximeter, by means of a sensor placed on her finger, measured the oxygen saturation of her blood. The “O 2 sat” is normally more than 95 percent for a patient breathing room air. The woman was wearing a face mask with oxygen turned up full blast, and her sat was only 90 percent.
“She’s not oxygenating well,” I announced in the flattened-out, wake-me-up-when-something-interesting-happens tone that all surgeons have acquired by about three months into residency. With my fingers, I verified that there wasn’t any object in her mouth that would obstruct her airway; with a stethoscope, I confirmed that neither lung had collapsed. I got hold of a bag mask, pressed its clear facepiece over her nose and mouth, and squeezed the bellows, a kind of balloon with a one-way valve, shooting a liter of air into her with each compression. After a minute or so, her oxygen came up to a comfortable 98 percent. She obviously needed our help with breathing. “Let’s tube her,” I said. That meant putting a tube down through her vocal cords and into her trachea, which would insure a clear airway and allow for mechanical ventilation.
Johns, the attending, wanted to do the intubation. He picked up a Mac 3 laryngoscope, a standard but fairly primitive-looking L-shaped metal instrument for prying open the mouth and throat, and slipped the shoehornlike blade deep into her mouth and down to her larynx. Then he yanked the handle up toward the ceiling to pull her tongue out of the way, open her mouth and throat, and reveal the vocal cords, which sit like fleshy tent flaps at the entrance to the trachea. The patient didn’t wince or gag: she was still out cold.
“Suction!” he called. “I can’t see a thing.”
He sucked out about a cup of blood and clot. Then he picked up the endotracheal tube—a clear rubber pipe about the diameter of an index finger and three times as long—and tried to guide it between her cords. After a minute, her sat started to fall.
“You’re down to seventy percent,” a nurse announced.
Johns kept struggling with the tube, trying to push it in, but it banged vainly against the cords. The patient’s lips began to turn blue.
“Sixty percent,” the nurse said.
Johns pulled
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