About The Story
While on call for the trauma service, third-year medical student Michael Higgins finds himself in an extraordinary situation. He is summoned to the ER to participate in the evaluation and management of a critically-injured patient and soon discovers that the blood-soaked, unconscious man lying before him is the same man who, one month earlier, committed a heinous act of violence that shattered Michael’s personal life. Following a lengthy emergency operation, the patient—known only as John Doe—is now under the care of the trauma team, of which student doctor Mike Higgins is a member. As John Doe’s condition gradually improves, Higgins’ personal life deteriorates further, but there might be a way to reverse the downward spiral: if he sees to it that John Doe never leaves the hospital, Michael Higgins’ world may right itself.
View the Glossary
Surgery is a technical endeavor. As such, this story is laden with surgical terminology. Taken in context, the meaning of these terms should be clear. If, however, you are interested in expanded definitions, photos of surgical instruments, X-rays and CT scans of pertinent pathologies, and links to videos of the ER thoracotomy described in the opening paragraph, please visit the glossary on this website. I encourage you to take a look. Gaining familiarity with the subject matter will enrich your reading experience, and the glossary is interesting in its own right.
Read an Excerpt
The heart was blue, almost black, and quivering like a sack of worms, a complete lack of organized contraction. The lung, a smoker’s lung, pink but marbled with dark pigment, billowed from the incision each time the respiratory therapist squeezed the football-shaped ambu bag. These were the images playing in Mike Higgins’ mind as he slipped into one of the top bunks in the surgery on-call room. He had just observed his first ER thoracotomy, the most coveted surgical procedure for a medical student to witness. A patient with a stab wound to the heart loses his vital signs. Two swipes of the scalpel from spine to sternum opens the left chest cavity. The ribs, cranked apart with a rib spreader. The aorta, cross-clamped. The pericardial sac, opened with scissors, exposing a penetrating injury to the right ventricle of the heart, which is sutured quickly, and the patient is rushed to the operating room for a definitive repair. Usually when a chest is “cracked,” the students are crowded out by residents, nurses, nurse techs, respiratory techs and lab techs. But not this time. Porter had grabbed Higgins, told him to get on a step-stool and watch over his shoulder. “You might learn something,” he’d said.
Higgins dropped his head to the pillow. It was 3:00 a.m., but he wouldn’t sleep tonight, not after that. He probably wouldn’t sleep for a week. Any lingering doubts about specializing in surgery had just been squashed.
Three beeps pierced his euphoria. “Trauma team, ER stat.”
He quickly silenced his beeper before the follow-up set of beeps woke the other third-year students sharing the room. A groggy voice called out anyway. “Dude, you’re a shit magnet. Have you ever had a night when you didn’t get pounded?”
“What do you expect for a level-one trauma center?” Higgins replied. “Wait ’til your rotation comes up.”
He climbed down and felt his way to the door—sparing the students on the upper bunks a blast of fluorescent light—and left quietly, slipping his white coat over his scrubs as he ran down the dimly lit hallway toward the eighth-floor stairwell.
Huffing and puffing, Higgins exited the stairs on the first floor and entered the main corridor of the ER. A high level of activity outside trauma bay one indicated where he needed to go. He trotted down the hall and squeezed his way into the room. Using a backboard, two paramedics transferred a patient from their gurney to the ER bed. A tall, imposing figure stood at the head of the bed with his arms crossed impatiently, his biceps bulging beneath the short sleeves of his green scrubs.
Dr. Conrad Porter was the chief resident of the trauma service. His close-cropped hair, muscular build, and total lack of facial expression made him look more like a Marine than a surgery resident. He listened intently as the senior paramedic gave report: “The patient is a John Doe, no ID, probably late twenties or early thirties, hard to tell with the facial swelling. He was the unrestrained driver in a single-vehicle MVA. The car hit a utility pole at high speed. The passenger, also unrestrained, was ejected through the windshield and pronounced dead at the scene.” As the paramedics reported vital signs, known injuries, and treatment administered in the field, Higgins studied the patient.
John Doe strained against heavy straps securing him to the wooden backboard. A cervical collar kept his neck aligned. His swollen head resembled a bloody pumpkin. Lacerations on his face, forehead and scalp seeped blood, and his T-shirt was covered with it. His jeans were dirty and torn, the tears old and frayed, not related to the accident. As John Doe squirmed and moaned, he opened his eyes. His stare was glassy and vacant. His groans, guttural. He would need to stay strapped to the board with his neck immobilized until X-rays ruled out spinal injury.
Higgins snapped to attention and turned toward Dr. Porter.
“Over here by me. Try to learn something.”
Higgins made his way to the head of the bed.
Although it would be hard for an outside observer to tell, Higgins was fairly certain Conrad Porter liked him. Higgins had been on the trauma service for a month, and during that time he had done his best to impress his chief resident. Higgins was bright and exhibited an untiring work ethic. He was dedicated to his patients, often staying at the hospital well into the evening, even when not on call. And he was usually among the first to arrive in the morning, ensuring that he was prepared for morning rounds. The residents and attending surgeons regarded Higgins as one of the best students in his class. He was obedient but also functioned well with minimal supervision. He never questioned authority, never complained about long hours, and was always where he needed to be. His fellow students, on the other hand, regarded him as a gunner and brown-noser, but Higgins didn’t care. Landing a top residency position required excellent letters of recommendation. The attendings wrote those letters, and they asked the residents for their input. If Higgins wanted to attend a prestigious surgery residency, impressing Conrad Porter was his highest priority.
“What do we do first?” Porter asked.
Higgins felt the heat rise. He had memorized the algorithm for treating trauma patients, but tonight he was in a position normally reserved for interns or junior residents. This was a rare opportunity, and he had to nail it. “First, connect the patient to the necessary monitors—EKG, blood pressure, pulse oximeter—and then establish intravenous access, fourteen or sixteen gauge IVs in each arm, and start IV fluids at the appropriate rate.”
“Right,” said Porter, “but there are four nurses doing those things for us. What should we do first?”
“Oh, yeah. The ABCs.”
“Airway, breathing, circulation.”
“So do it.”
“His chest is rising and falling, which indicates his airway is open.” Higgins put his stethoscope in his ears and slid the diaphragm under the man’s bloody T-shirt. He listened to the left side of the chest, and then the right. “He has bilateral breath sounds, but they’re shallow. He’s moving air, but not enough. He needs to be intubated.”
“Yes. You can tell by looking at him that his respirations are agonal, and check out the pulse oximeter. His O-2 sat is dropping. We need to get a tube in him before he codes.”
The respiratory therapist had already attached corrugated tubing to the ventilator and was opening an intubation tray.
“That covers airway and breathing. What else? Quickly.”
“Circulation. His blood pressure is eighty over fifty. He needs some fluids.”
“Yes.” Porter looked at the nurse cutting off John Doe’s pants. “Donna, run in two liters of lactated ringers as fast as you can, and get six units of O-negative packed cells from the blood bank.”
“Yes, Doctor.” Donna handed the shears to a younger nurse and left the room.
Porter turned toward Higgins. “You get one shot at intubating this guy, and remember, you can’t tilt his head because we haven’t cleared his C-spine yet.”
“Okay,” Higgins said.
He tried to open John Doe’s mouth, but the harder Higgins pried, the more Doe clenched his jaw and thrashed against the restraints.
Dr. Porter snapped at the young nurse with the shears. “Forget about the pants. We need to paralyze this guy. Give him a hundred milligrams of succinylcholine, IV push.”
“Yes, Dr. Porter,” she replied. “Should I sedate him with a narcotic as well?”
Porter scowled. “Why would I want to give this patient narcotics?”
“Well,” she said timidly, “if he’s paralyzed without any narcotic sedation on board, he’ll be awake but unable to move. He’ll be able to sense everything going on around him, but he won’t be able to respond, or react to pain.”
Porter gave the nurse a disdainful shake of the head. “Typical nursing school BS,” he mumbled.
Higgins was glad he hadn’t asked the question.
“First of all,” Porter said, “this man is gorked. He’s out of it. He has no idea what’s going on around him. Secondly, if he does hear and understand us, he’s not letting on. Thirdly, it’s pain that’s keeping him alive. He’s lost a lot of blood. His adrenal glands are pumping epinephrine into his bloodstream as fast as they can make it. The epinephrine is keeping his blood pressure up until we can get a couple units transfused. If we sedate him and blunt his pain response before we replace his blood loss, his pressure will bottom out, he’ll have a cardiac arrest, and he’ll die. And finally, succinylcholine is a short-acting paralytic agent. The paralysis will wear off in three minutes. Didn’t they teach you any of this stuff in school?”
The nurse injected the paralytic agent, and in less than thirty seconds, John Doe’s muscles began to twitch—first the larger muscle groups of the arms and legs, then the facial musculature. After a few moments the twitching stopped, a sign that the patient was now fully paralyzed.
Higgins opened John Doe’s mouth, inserted a laryngoscope, and easily exposed the vocal cords. He slid the endotracheal tube between the pearly-white cords, advanced it about three centimeters into the trachea and inflated the cuff at the end of the tube, forming an airtight seal.
“Well done,” Porter said.
Well done—two words that qualified Higgins’ night as a major success. He had intubated an unstable trauma patient on the first try, even with the man’s head strapped to a backboard, a feat that will be remembered by his chief resident. He stepped back and stood triumphantly as Porter took over: “Bag him until his O-2 sat is up, then get him on the ventilator. Run in two units of O-neg as soon as it gets here. Have radiology shoot his spine so we can get him off this board.”