One Rainy Day with Trauma

By Dan Munoz
School of Medicine, '04

Ruminations on life as a medical student

Rain was a good sign.

Peering out an eighth-floor window of the Nelson building, I could see the silhouette of the Baltimore skyline fighting a losing battle against dense Saturday morning fog. Three weeks on the Halsted trauma surgery service had taught me that bad weather was often a harbinger of relative calm on the streets of East Baltimore. It meant a break in the numbing stream of stabbings and shootings in our city.

After checking on our patients during morning rounds, my surgical intern and I settled down for a light breakfast in the hospital cafeteria. Three bites into my morning bagel, our pagers went off simultaneously. The display read "Delta Trauma, Adult ER, stab wound, ETA 3 minutes." We scrambled toward the emergency room. The surgical intern was called as a necessary member of the team. My role in trauma situations was more nebulous. I was there primarily to learn and to assist when the team deemed it appropriate.

Outside the trauma bay, I traded my white coat for a protective gown and a faceguard. From down the hallway came the rattling crescendo of an approaching stretcher. A young male stabbing victim rolled toward us, straddled by an out-of-breath paramedic performing CPR. As the trauma team took over, the paramedic wandered back into the hallway. He hunched over, dripping sweat on the floor, his leg of this macabre relay finished.

A young attending surgeon took control. As the trauma surgeon on call, the buck stopped with him. Coordinating the whole team's effort, he barked orders with a voice that reflected confidence and urgency.

A senior resident stood at the head of the stretcher. She ventilated the unresponsive patient. Her eyes methodically scanned each team member around the stretcher, ensuring that the attending's orders were promptly carried out. Her firm tone communicated that in just a couple of years the buck would stop with her.

My surgical intern documented the second-by-second events and filled out paperwork necessary for emergency labs. His gaze only occasionally hit the center of the room-the patient-as if to mask how overwhelmed he might feel when and if he became responsible for coordinating such a massive effort.

I stood at the doorway. The situation unquestionably required more experienced personnel. I committed to taking it all in, to focusing on the medical strategies implemented in the face of terror.

Nurses and technicians scrambled to prepare needed equipment as they tried to ascribe some logic to the labyrinth of tubing and monitors already in use. At one point, I counted 17 people in the room.

The patient was in ventricular fibrillation, a fatal heart arrhythmia if left uncorrected. The attending surgeon decided to perform a thoracotomy there in the ER, a last-ditch attempt to restart the patient's heart and control massive bleeding in the chest. In seconds, the victim's left chest was open, his heart and lungs exposed to light for the first time in his 32 years.

"Clear!" All hands were off the patient.

The victim's body flopped as paddles sent an electric shock directly to his heart. Miraculously, his heart regained a regular beat. With his hand literally grasping the major bleeding source inside the patient's chest, the attending surgeon ordered our team to the operating room. Surgical repair of the injury was the only hope for this man.

I rode the elevator from the ER to the OR with Officer Johnson of the Baltimore City Police Department. He smiled nervously and in a trembling voice offered, "This is my first day…"

"Trust me, I know how you feel," I said, redefining the notion of understatement.

For hours, surgeons and anesthesiologists worked to keep the victim alive. The controlled setting of the operating room creates a sense of calm and focus impossible in the emergency room. But it does not necessarily change the outcome. Despite everyone's best efforts the patient succumbed to an irreversible arrhythmia. I looked around at the stunned faces of residents and OR staff. Three hours and 39 minutes after my pager sounded, the attending surgeon asked if there were any objections to stopping. Hearing none, he called the time of death.

The attending surgeon stepped away from the table, his gown drenched in blood. After years of training that can harden even the most compassionate of souls, his face told a different story. Staring dejectedly at the operating table, he took this defeat by the streets of Baltimore personally.

That evening, I collapsed on my couch with a plate of micro-waved leftovers, my first glimpse of food since the morning bagel that never was. Flipping channels aimlessly, I eventually settled on the local news. The third story caught my attention. In a mechanical tone the news anchor relayed the story of "a young black male who this morning was stabbed in East Baltimore in what may have been a domestic dispute. He was taken to Johns Hopkins where doctors in the operating room worked to save his life. He later died."

The local news had just condensed a 32-year-old life, a family's tragic loss, and hours of a medical team's adrenaline, uncertainty, effort, and ultimate defeat into a dry 10- second sound bite before a commercial about ketchup.

Outside, rain continued to fall.