The phone rattled Alex awake on the couch. After knuckling his eyes, he checked the clock. 12:03 a.m. Last he remembered, he was sitting there reading a medical journal. Most lights were off, so Lisa had long since gone to bed. He picked up the cordless phone. “Cutter here.”
“Doctor Cutter, Harvey Leventhal. Got a GSW to the head over here at the trauma center. Tangential right hemisphere. We’re scanning him now, but I’m taking him to the OR soon as he’s off the table.”
“Be right in.” Leventhal was an extremely competent senior resident who Alex predicted would become a dynamite chief resident next year, so there was no need to rush.
He caught up with Leventhal in OR One just as the anesthesiologist finished taping the patient’s endotracheal tube securely in place. Leventhal was arranging CTs on the view box, the scrub and circulating nurses flying about in the hurriedly orchestrated pace of an emergency case.
“Got a tangential furrow through the fronto-parietal bone, driving in bone frags here, here, and here,” the resident said, tapping obvious bone fragments on the scan.
“What’s your plan?” Alex asked rhetorically. He heard the sudden hiss of steam escaping from the autoclave as the circulator unlocked the thick, reinforced stainless-steel door.
“GSW 101. Debride the wound, close the dura, and then play hockey.”
Alex laughed. “Yeah, get the puck out of there. Gotcha. Good plan. Let’s go scrub up.”
At the scrub sink, Leventhal said, “I put in a call for the Baptist resident, but he’s tied up at the moment. Soon as he gets here you can head on back if you want.” At that point, Alex would have fulfilled his oversight requirements. If he left the OR when Leventhal’s assistant arrived, it would signal a vote of confidence in the resident’s abilities.
Alex assisted Leventhal by squirting irrigation over the ragged wound edges while he worked at controlling the bleeding. Tangential wounds were often hard to close because the bullet blows out a furrow of skin, producing ragged damaged edges that have to be removed to produce a clean, even closure. This results in less scalp available to cover the same area of skull, making the closure tricky. And unlike a clean surgical wound, these were often grossly contaminated from hair and small bits of skin and other debris. Once the wound edges were cleaned up and the bleeding controlled, Leventhal began carefully picking out bits of contaminants, flicking them off the tips of the forceps onto the floor to keep the operating area sterile. Alex squirted more saline into the field, assisting in the cleaning process as Leventhal worked.
With the superficial areas now debrided, Leventhal placed a self-retaining retractor to spread open the wound so he could get a better estimate of the underlying skull damage. The bullet had made a linear groove high along the left temple, pushing bone fragments through the dura into the brain. Luckily, because the bullet struck tangentially, most of the force had been expended along the bullet trajectory instead of radially into the brain substance. One by one, Leventhal picked out the bone chips with a hemostat. Because the fragments were contaminated with hair and bits of skin, and because bone can’t be autoclaved without killing it, he dropped these pieces into a bucket on the floor at their feet. In six months or so, if the wound healed without signs of infection, the scar could be opened and acrylic used to fill in the skull defect for a better cosmetic result.
The junior resident finally walked into the OR just as Leventhal was getting ready to patch the dura and close.
“Go ahead and scrub,” Alex told him. “Leventhal, think you can handle the dura?”
“Figure I’ll patch it with temporalis fascia,” he replied, referring to the heavy connective tissue encasing the muscle to the jaw.
“Perfect.” Alex stripped off his gloves. “I’ll write an op note.”
In the darkened bedroom, Alex carefully slid between the sheets without awakening Lisa, the glowing clock radio now showing 3:41. Sleep would most likely be impossible now, yet he rolled onto his left side to begin his relaxation exercises, hoping to be surprised in the morning by the alarm. He thought about his life, about how differently he lived from the patient just operated on: an unidentified African American male, perhaps mid-twenties, literally pushed out of a moving car in the Emergency Room parking lot, the only witness to the drop too confused and shocked to note even the make of the car, much less who drove or anything else of importance to the police. The kid, of course, had been stripped of all identification. Might be gang related and likely was drug related. No one knew any particulars, not that that information was medically relevant. But the thing was, the patient’s history was important because victims of street crimes typically were at higher risk for AIDS and hepatitis, two diseases readily transmitted to a surgeon from an accidental needle stick, especially during a rushed emergency surgery. Alex thought back to Robert Sands, the pediatric neurosurgeon who had been forced into early retirement for exactly this reason. And guess what? In spite of these increased risks, the clinic was likely to receive no reimbursement for this surgery. Or cases like it. The gangbangers and petty criminals, usual patients in the trauma center, didn’t carry Blue Cross cards. Although he didn’t enter medical school with the goal of making money, he did believe he should be compensated for his services.
Tossing and turning, he watched the glowing digits increment minute by minute. At 4:45, still unable to sleep, he slipped silently into the bathroom and shut the door to begin preparing for another day, another month, another 5:30 clinic business meeting. Thank God he had clinic instead of surgery that day.