Saturday, March 31, 2012

Trauma Surgery

I wake up in the pitch black to a sound, some sort of beeping that won’t go away.  Waking up is arduous; my limbs feel like tree branches, even my blood feels sluggish.  I don’t just not know where I am, I don’t know who I am, or what “awake,” is.  That is how deeply I was asleep. 

And then it dawns on me, that I am a medical student and I am in the on-call room, and that god-awful noise is my beeper.  I reach for my glasses and end up knocking the lamp and my pager off the bedside table.  I flail around in the sheets, trying to reach down and right the lamp.  Finally, I close my fingers around the pager and silence the alarm.  I think seriously about going back to sleep, but I don’t.  I read the tiny display on the beeper, “trauma alert: 39 yo male.”  I struggle to stand.  The beeper goes off again while I am still holding it.  More details: “trauma alert: 39 yo male. sledding accident.”  This should be good.

I stumble into my clogs, pull a surgical cap over my bed-head, and put on my white coat.  I shove a granola bar into my mouth as I trot off down the hall to the maze of tunnels that will take me to the trauma bays.

Trauma Male #1 is just being rolled off the ambulance as I arrive.  He is sitting up on the gurney, neck braced, moaning and holding his stomach, a line of blood dripping from his right nostril onto his shirt.  I pull on a gown, gloves, and a mask, and dig the shears out of my white coat pocket.  As the medical student on the trauma team, my main job seems to be Carrier of the Shears, which are useful for removing pesky things like clothes and bandages.

And this is no exception.  As the nurses swarm the patient and start shouting out vital signs, my chief motions me over, “Cut off the shirt and the pants,” he says, and then whirls off to make sure we are next in line for the CT scan.

I sidle up to the gurney, trying to introduce myself to the patient before I cut off his clothes and avoid getting in the way of the nurses, who seem to be doing actually important things, like placing IV lines and taking a history.

I stand to the left side of his head as he tells the nurse, “I was in the toboggan and couldn’t steer and we turned sideways and slammed into a tree.”  He points to the upper left side of his abdomen. “It hurts right here,” he draws a perfect circle over his spleen.  Hmm. I remember that spleen lacerations are graded, but I can’t remember what the criteria are.  Hopefully I will have time to sneak off and look this up before my resident pimps me on it.

“Hi sir, I just need to cut off your clothes so we can see your injuries without moving you too much,” I tell him. 

“You don’t need to cut them, it’s just right there, I can just pull my shirt up.”

Well shit.  Cutting off the clothes is my one job, and my resident will not be happy with me if I fail to do it.  Also, while I see his point that the area is already pretty accessible, it could be that this pain is distracting him from other injures. 

“I’m sorry sir, but we need to make sure you don’t have any other injuries.  I will cover you up with this sheet--”

He cuts me off, “please don’t cut my clothes.”

My resident appears behind me, holding his own pair of shears. (Way to make me feel useless.)  “Sorry sir, it is protocol here in the ED.” And then starts cutting.  “You get that side,” he says to me.

So I do, despite the fact that I am pretty sure this is assault.  Gritting my teeth, I start at the ankle and cut his jeans all the way up the leg to the waist band.  My resident does the same, and soon we are able to peel off his pants.

Which is when we notice that in addition to whatever sled-related splenic injury he has sustained, Trauma Male #1 has been shot in the penis.

My eyes dart up to the patient’s face – he looks horrified and humiliated and also a bit pale.

I have a sinking feeling in the pit of my stomach.  Partially, I am sure it is a visceral reaction to this type of injury, which I must admit squeaks me out the same way the all-wrong angle of broken bones still makes me queasy.  But the other part of this feeling is just knowing that we are in a rural hospital in Virginia.  I don’t believe the social and psychological awareness of the medical staff here is going to be sophisticated enough to deal gracefully with any of the scenarios that could lead to a man being shot in the penis.  We deal well with tractor accidents.  But mental illness? gender dysphoria? domestic violence?  These are not our strong suits.  And above and beyond the relatively temporary violation of having his pants cut off against his will, I have the sense that this man is about to have a whole prolonged interaction with healthcare that will be marked by violation.  And of course, I will participate in it. 

The resident raises one eyebrow and then sort of shrugs.  There is some dried blood around the patient’s crotch, but no active bleeding.  No one else on the trauma team seems to have noticed our discovery – it’s a small caliber hole and I guess most people make an effort not to stare at the patients’ junk.  My resident grabs the sheet from my hands and covers the patient up before directing the team to roll him onto one side and inspect his back.  We roll him up, and the intern runs her fingers down his spine. “No visible injuries,” she reports, and we lie him back down.

The resident listens to his heart and abdomen, pokes his belly a bit to elicit some groaning. Apparently nothing is concerning.  “Ok,” he says, “take him to CT.”  Lead-covered technicians appear and whisk him down the hall to the radiology suite.  I stay behind and look at my resident.  “I’m paging urology, go see if he has any spleen lacs.  If not, he’ll be on their service.”

Obediently, I trot off to the radiology control room.  If his penile injury is visible on CT, it certainly isn’t visible to me, and no one else comments on it.  We stare at his spleen, which looks normal.  The radiologist confirms – no laceration to the spleen.  We also “clear” his cervical spine – meaning we don’t see any fractures, so he is allowed to remove the horribly uncomfortable collar.  Normally we would probably discharge him now, but the resident appears to tell to technicians who are maneuvering him off of the CT scanner and back onto the gurney, “take him to room twelve.”

Room twelve is one of the more private ER rooms, with a real door that closes and is not made of glass.  Usually this room is occupied by women with gynecological complaints, so that a pelvic exam can be performed in relative privacy.  We wheel Trauma Male #1 in there.  A nurse gives the resident a questioning look and he says, “we’re waiting on a consult from uro – just keep him comfortable until they get here.”

And then the pagers are going off again – mine, the resident’s, the nurse’s.  “Trauma alert: 62 yo male. MVA.”

“Motor vehicle accident,” my resident explains, “bay two.”

I ready my trauma shears, hoping my task is less complicated this time. 

After the whirlwind of Trauma Male #2, I try to go back and check on #1, but he is nowhere to be found.  It is hours later, he could have been admitted to urology’s service or discharged home or he could have left AMA (against medical advice).  I don’t actually know his name or medical record number, so I can’t check the computer.  On our next shift together, I ask the resident, and he says he has no idea either.  Then he says, “I hope that guy did ok.”

I’m impressed with the way the resident handled the situation – maybe not with a nuanced theoretical understanding of the various issues that could lead to someone shooting himself (or being shot by someone else) in the penis – but at least with decency and discretion.  Decency and discretion delivered immediately after he cut the man’s clothes off against his will (which I still think is wrong and feel wrong for participating in).  

But it’s good to be reminded that people aren’t all one thing.  We aren’t either all good or all bad, we have good moments and bad moments.  I hope that Trauma Male #1 did ok, too.  And I hope that I will do better next time.

1 comment:

  1. I always enjoy reading your posts. Your perspective is so refreshing. (And you line about smuggling a frozen turkey the other day made me snort soda out my nose!) Keep posting, please :)