Thursday, February 6, 2014

A CT Scanner and a Chest Tube


This story does not occur in the South, but one of the three pivotal characters is a bona fide Southern lady (that’s me). Furthermore, this is by far one of the most hilarious surgery stories in my repertoire – and it all revolves around a CT scanner and a chest tube. How is that even possible, you ask…. It all starts with a very unique attending trauma surgeon who I’ll call Dr. Eisenhower. Dr. Eisenhower was known for his often surly attitude with the residents and only slightly less surly attitude with the nurses and other hospital staff, but get him in front of a patient’s family, and he threw on the charm. He actually is a big softy at heart – you just have to get him in a one-on-one situation so that he can preserve his “bad boy” reputation. This attending was also well known for his control issues.

I’ll detour from the story to temporarily explain a few things about becoming and being a physician – particularly a surgeon. After undergraduate studies, the journey usually begins with medical school – if no diversions are taken to try to backpack through Europe (read: escape in hopes of never returning to the guaranteed pain that comes with medical training). Some do prefer to start slowly with pharmacy school or some PhD degree remotely related to medicine. These are all delay tactics, and I gladly partook of my own one-year delay. Medical school is designed to give you the background, the science, the foundation to move further into both the science AND art of medicine. Clinical rotations (those in the hospital or physicians’ private practices) are sometimes tough and sometimes easy – depending on the specialty and the attending(s) you get assigned. Mostly during those years, though, the attendings are still in a mode of wanting to either impress you or intimidate you…or both. They’ll regale you with their toughest surgeries, most hilarious screw-ups that their residents were guilty of, and show off their knowledge/skills. They still remember to treat you like gum on the bottom of a shoe – a nuisance following them around that they can’t quite get rid of. I have many stories of those days down in Savannah – and many pleasant and funny stories from there, but I’ll save them for another time.

Next you move on to internship. If a medical student is treated as gum stuck on a shoe, the interns are treated more like dog poop on the bottom of the shoe – not only does it follow you around and is difficult to get rid of, but it also stinks with every step taken leaving a wake of waste in its path. Interns are generally given simple tasks known as scut work. These tasks include things like collecting laboratory values on all the patients and committing them to memory before rounds; changing all the dressings on the patients at appointed times; collecting blood from patients (back in the old days – and currently is done when the nurse(s) have been unsuccessful); transporting patients to studies and tests if need be; answering all pages from the nursing staff; walking patients that haven’t been out of bed enough; studying each patients’ medical problem and surgical/medical options; etc. Interns do most of the least desired work and are in the speak-only-when-spoken-to category. They generally get no notice from the attending unless the intern has made an error or the attending is in a particular mood to quiz someone to death.

As you move from internship to residency, you are starting to get more responsibility but not much more in the way of respect. You certainly increase the amount of “dressing down” that occurs in the more rigorous specialties. It’s a right of passage in a way to routinely have your superiors – senior residents, fellows and attendings, alike – all point out your failings and make you feel foolish in front of anybody and everybody within earshot of their very loud voices. Now, you are getting to do some supervising of the students and interns, and you get to actually participate in more and more surgeries rather than just watching them and holding retractors during long procedures. Each year that you move up in residency, you slowly build more respect, hone your skills and learn more complex surgeries. Autonomy in patient management increases, and some attendings may become friendlier with you – while others insist on reminding you that you are still a minion. Fellowship is sort of the highest level of this but with much more conviviality with the attendings.

So, after that digression, back to Dr. Eisenhower… He definitely fell into the category of one of those attendings who wanted to make sure you and everybody else knew that he – and he alone – was “the decider.” All the residents, nurses and other ancillary care staff would often quote his most famous and incessantly repeated line, “I’m in charge here.” – a statement he made every time he entered the trauma bay, operating room or any critical situation. We could be elbow deep in blood from some horrific trauma and still acknowledge that – yes, sir, you are in charge…we were just holding things together until you arrived.

One late night, a critical trauma came flying into the trauma bay after a motorcycle crash – pale, gasping and shaking with obvious multiple extremity fractures. Besides that, we actually KNEW this guy! He’d actually been in less than a year earlier due to a different motorcycle crash. However, this time he had more than just bruised lungs and broken bones. We followed our standard Advanced Trauma Life Support protocol as we do for all our patients. After placing chest tubes on both sides to relieve his breathing problems, splinting his fractures and stabilizing him with pain medications, we set off for the all-but-mandatory CT scan. When brought in as a critical trauma patient (especially with blunt trauma), it’s nearly impossible to avoid a CT scan of something – or sometimes everything. Now, Dr. Eisenhower was not a calm man, and everything was to be done now – go – hurry – what’s going on – go! Despite being accustomed to his intensity, we did occasionally get rattled by his sense of urgency and hurry a li’l too fast from one task and/or place to the other. His sense of urgency was typical that night. On cue, we rushed this motorcycle patient (we couldn’t remember his name yet) to the CT scanner which involved moving him from the trauma bay gurney to the CT table without dislodging chest tubes, foley catheters, IV lines, etc. The trauma team – including our fearless, if even slightly frantic leader – retreated behind the lead wall to watch the scan as it came up on the computer monitors. Instantly, we could see the patient had a Grade 3-4 splenic injury and was bleeding internally – A LOT. In other words, he needed to go to the Operating Room (OR) immediately for a splenectomy (removal of his spleen) and to search for any other sources of bleeding and/or injury. Thus, the boss wanted us to move the patient posthaste to the OR.

That’s when it happened – when things went so hilariously awry. Here is why the story is now something of a legend at that Trauma Center. In his hurry to get us to move the patient back to the gurney and rush to the OR, Dr. Eisenhower jumped in to help with the moving which is uncommon for most attending physicians. During the move, he accidentally stepped on one of the patient’s chest tubes and it’s connection to its water seal chamber snapped off. The important part about all that is, of course, the patient needs to have proper chest tube suction and drainage, but also that this tubing that pulled out is made of material akin to a large, thick rubber band. Thus, when it snapped back, it popped the attending surgeon EXACTLY in his “male region” causing him to fall directly to the floor, curled up in a fetal position. As the rest of us realize what has happened, we were struggling with carrying on our mission to get the patient rushed to the OR; restraining ourselves from also falling on the floor (with laughter); and feeling a tiny bit of concern that maybe we should help Dr. Eisenhower. We quickly regrouped as – from the floor, holding himself and rocking back and forth – we heard, “GO! JUST GO! Get to the OR NOW!”

And off the patient, myself and the rest of the trauma team went to the OR. The chest tube was promptly fixed, and since the patient was rapidly losing blood – despite aggressive resuscitation by the trauma nurses and anesthesiologist – and needed immediate surgery, I started right away. As the Chief Resident for the Trauma Service, I couldn’t just let the patient bleed to death while the attending was incapacitated on the radiology room floor. By the time I had cut open his abdomen, clamped the bleeding arteries and veins of the spleen and was just about to remove the destroyed li’l spleen from the patient’s body, Dr. Eisenhower came hobbling into the OR. With his hands still cupping his man parts, he peered over my shoulder and into the patient’s open abdominal cavity. He started barking instructions for resuscitation and surgical maneuvers that had long since been performed. We all just nodded and kept doing our work. By the time he was able to gather himself and scrub in, it was double check for bleeding, wash out the abdomen and close it up time. Indeed, the attending diligently checked my work: the suturing, the knots, the evaluation of the abdominal organs and intestines, and, of course, the examination of all four quadrants of the abdomen plus inspection for abnormalities in the retroperitoneum. Satisfied, he looked up and said, “I’m glad we got to him in time. You can finish up here, right?” Then Dr. Eisenhower hobbled right back out of the Operating Room.

Later... when the patient was safely out of the OR where he was doing well in the Intensive Care Unit, and his family had been updated, we were finally able to laugh. Much later, though, once the patient was recovering and discharging from the hospital entirely, we told and retold that story to everyone and laughed so hard our sides hurt each time we recounted that hilarious scene. We laughed for weeks – no YEARS. If you just mention the CT scanner and chest tube incident to anyone at that Trauma Center, it will immediately incite laughter and various versions each eyewitness adds as time wears on. It’s LEGENDARY – just ask the x-ray tech on roller skates. Oh, that’s an entirely different story for a different time…

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