Tuesday, April 7, 7:52 A.M.
The ER was a madhouse. A continuous stream of injured patients was being frantically wheeled in and distributed to various exam rooms. The trauma rooms had already been filled. Several of the senior ER physicians were doing quick triage out on the receiving dock, as patients were unloaded from ambulances. The more seriously injured were immediately handed off to waiting groups of doctors and nurses who started assessment and treatment even before the gurney got into an exam room. Those patients with relatively minor injuries were rolled off to the side to wait their turn.
Neither Lynn nor Michael had much experience with emergency medicine other than a brief didactic exposure in lectures and a short tour of the department during third-year surgery, and they didn’t know any of the emergency room personnel. Although the house officers they arrived with had a general idea of what to do, Lynn and Michael had no clue. Lacking any specific destination, they ran up to the front desk. At first no one paid them any attention. What they didn’t realize was with white coats over scrubs, the nursing staff took them for residents, not medical students.
“Can we help?” Lynn asked one of the harried nurses who seemed in charge, as she was directing traffic more than anyone else, hollering orders to various people. She was standing just behind the chest-high counter of the ER check-in desk along with a roiling crowd of almost twenty people. Everyone was busy with phones and paperwork, some abruptly racing off to one of the rooms while others arrived. Over the babel of voices the sounds of sirens could be heard, as more ambulances pulled up outside.
At first the nurse whom Lynn had addressed just looked at her but didn’t respond. Her eyes were distantly focused, suggesting her mind was processing too many things at once. As Lynn repeated her question, the woman recovered from her mini-trance. She reached out and snapped up a clipboard from a pile in front of her. She handed it to Lynn, saying, “Take care of this case! Exam room twenty-two. Male with a mild breathing difficulty. Blunt-force chest trauma.”
Before Lynn could respond, the charge nurse yelled to a colleague across the room to bring down several more portable X-ray machines from X-ray and to get them into the trauma rooms. Then she turned to another nurse behind her and told her to check on what was happening in Trauma Room 1 to see if the patient was ready to be sent up to surgery.
Lynn read the patient’s name: Clark Weston. It was scrawled in longhand on the ER admission form, along with a chief complaint: breathing difficulty, blunt trauma. Lynn noticed the blood pressure was normal although the heart rate was a bit high, at 100 beats a minute. A scribbled note said: mild dyspnea but good color. Sternal contusion but no point tenderness over individual ribs. No lacerations. Extremities normal. No broken bones. That was it. There was nothing else. After a quick glance to see if she could again get the head nurse’s attention—which she decided was unlikely, as she had momentarily disappeared—Lynn looked at Michael, who she knew had read what was on the clipboard over her shoulder. “What do you think?” she asked. “Can we handle it?”
“Let’s do it,” Michael said. Both realized that the head nurse had no idea they were medical students. Both were wearing lanyards with their ID cards around their necks, but one had to look at them closely to see that there was no MD after their names.
Despite the chaos and no one to ask for directions, they found Exam Room 22 without much difficulty. The door was closed. Lynn went in first, and Michael followed right behind her, pulling the door closed behind him. The room was an island of tranquillity in the middle of a storm.
Alone in the room, Clark Weston was supine on a gurney but propped up on both elbows, struggling to breathe with shallow, rapid respirations. He was a middle-aged blond man, mildly overweight, and fully dressed in a suit jacket, white shirt, tie, and dark slacks. The tie was loosened. The shirt was open and pushed to the side, revealing a pale, expanded chest with obvious central bruising. Both medical students immediately noticed the man’s color was not good, contrary to what was noted on the admission form. His skin had a bluish cast, as did his lips. His expression was one of desperation. Concentrating on trying to breathe, he couldn’t talk. It was obvious he thought he was about to die.
Lynn ran to one side of the gurney while Michael went to the other. Both felt an instantaneous rush of terror with that sudden realization that this was no mere difficulty breathing, and as neophytes, they were in totally over their heads, facing a patient in extremis.
“I hope you have some idea of what to do,” Michael croaked.
“I was counting on you,” Lynn said.
The patient, hearing this exchange, rolled his eyes before closing them to concentrate on trying to breathe.
“I better get a resident,” Michael blurted, and before Lynn could respond, he bolted from the room, leaving the door ajar.
Left on her own, Lynn dashed over to an oxygen source, turned on the cylinder, and then rushed back to put a nasal cannula around the patient’s head. Placing the bell of her stethoscope on the right side of his chest, she listened. The man was breathing so shallowly and rapidly, she could barely hear any sounds. The competing noise from the ruckus coming in through the open door didn’t help.
At that point Lynn realized how overly expanded the man’s chest was. It was as if he was blown up like a balloon. What did that mean? She tried to think and access her memory banks about what she had been taught in physical diagnosis, but her exhaustion combined with the terror engendered by her feelings of incompetence made it difficult. She vaguely remembered that an expanded chest meant something important, but what? She didn’t know.
Moving the bell of the stethoscope to the left side of the man’s chest, Lynn was surprised to hear almost nothing. At first she thought it was her problem, meaning she was doing something wrong, but then she compared the two sides. It was apparent that she could hear breathing sounds on the right, even if they were bearly discernible, and nothing, or close to nothing, on the left. Suddenly an idea of what was going on began to form in her mind. Taking the stethoscope out of her ears, she tried percussion: placing her left middle finger on the patient’s chest and taping it with the middle finger of her right hand. The resultant sounds between one side and the other were different. The left side was hyper-tympanic, like a drum, compared with what she heard on the right side.
Michael flew back into the room, panting from exertion. “I couldn’t find anyone free. The only person I found was an ER doc two doors down struggling with a dislocated shoulder. He promised he’d be here as soon as he got the arm back in the joint. How is the patient doing?”
“He’s getting oxygen, which should help some,” Lynn shot back. “But he is in trouble. But I think I know what is going on.”
“Clue me in!” Michael demanded.
“Listen to his chest! See what you think. But do it quickly.”
Michael struggled to get his stethoscope in his ears. While he listened first to the left side, then to the right, and then back to the left, he kept his eyes on Lynn, who was taking the man’s pulse. “There’s no breath sounds in the left side,” Michael said.
“Try percussion!” Lynn said. “But do it fast. His heart rate is up to one hundred twenty. That can’t be good.” Lynn could feel her own pulse in her temples beating almost as rapidly.
Michael quickly did as Lynn suggested. The hyper-resonance on the left was immediately apparent, and he said as much.
“Does that ring any bells to you?” Lynn said. “Especially since he has dilated neck veins.” She pointed.
“Tension pneumothorax!” Michael blurted.
“My thoughts exactly,” Lynn cried. “If so, it is a real emergency. His left lung must be collapsed, and with every breath, the right is being compressed. He needs an X-ray, but there’s no time.”
“He needs a needle thoracotomy on the left!” Michael shouted. “And he needs it now!”
In a panic, the two students regarded each other across the body of the patient. For a second they hesitated, even though they were frantic. Neither had ever seen a needle thoracotomy performed, much less done one. They’d read about it, but to go from book learning to actual performance was a giant step.
“How soon do you think the ER doctor might get in here?” Lynn demanded anxiously.
“I don’t know,” Michael said. Perspiration appeared on his forehead.
“Mr. Weston,” Lynn yelled as she gave the man’s shoulder a shake. The patient didn’t respond. Instead he collapsed supine onto the gurney, no longer supporting himself on his elbows. “Mr. Weston,” she called louder, with a more significant shake to his shoulder. Nothing. The patient was no longer responding.
“We can’t wait,” Lynn said.
“I agree,” Michael replied. The two of them rushed over to a crash cart that had all sorts of emergency equipment. They grabbed a large syringe, a sixteen-gauge intravenous cannula, and a handful of antiseptic pledgets. Then they rushed back to the patient.
“My memory is that it is supposed to be done in the second intercostal space between the second and third rib.”
“You do it!” Lynn yelled, thrusting the cannula into Michael’s hands. “How the hell do you remember such details?”
“I don’t know,” Michael retorted as he quickly snapped on a pair of sterile gloves. He then tore open the sterile wrapping on the cannula. It had a needle stylus to facilitate insertion.
“What if it is hemothorax and there is blood in there instead of air?” Lynn questioned anxiously. “Would we be making it worse?”
“I don’t know,” Michael admitted. “We’re in uncharted territory here. But we got to do something or he’s going to check out.”
Lynn tore open several alcohol pledgets and rapidly swabbed a wide area below the patient’s left collarbone. Michael positioned the tip of the cannula with its needle stylus over what he thought was the correct position. He’d located it by palpating the area and feeling the bony landmarks. Still he hesitated. It was a daunting task to blindly plunge a needle into someone’s chest, especially the left side, where the heart was.
“Do it!” Lynn snapped. She knew that she and Michael were an example of the blind leading the blind, but the needle thoracotomy had to be done, and it had to be done immediately. The patient’s color had deteriorated despite the oxygen.
Gritting his teeth, Michael pushed the catheter through the skin and advanced it until he felt the needle tip hit the rib. He then angled it upward slightly, and pushed again. He could actually feel a pop after advancing the needle another centimeter or so.
“I think I’m in,” Michael said.
“Great,” Lynn said. “Take out the stylus!”
Michael pulled out the stylus. Nothing!
“I guess I have to advance it a bit more,” Michael said. “I must not be in the pleural space yet.”
“That, or we have made the wrong diagnosis,” Lynn said.
“Now, that’s a happy thought,” Michael added sarcastically. He reinserted the stylus and then pushed deeper into the patient’s chest. He felt a second pop. This time when he removed the needle, both he and Lynn could hear a rush of air come out through the needle like a balloon being deflated.
Lynn and Michael’s eyes met. Both allowed a tentative smile. Over the next few minutes their smiles broadened as the patient’s breathing and heart rate improved, as did his color. He also slowly returned to consciousness. Lynn and Michael had to hold his hands to keep him from reaching up and touching the cannula sticking out of his chest while they waited.
“Maybe we should do a residency as a single person,” Michael said. “I think we make a good team.”
Lynn smiled weakly. “Maybe so,” she agreed, pushing away the thought that she wished she were heading up to Boston with Michael.
Just then a blood-spattered ER doctor by the name of Hank Cotter and a nurse rushed in. They went directly to the patient, crowding Lynn and Michael to the side. While the nurse took Clark’s blood pressure, Hank listened to the man’s chest. He saw the needle thoracotomy.
“Did you guys do this?” he questioned.
“We did,” both Lynn and Michael said in unison.
“Collectively we decided it was a tension pneumothorax,” Lynn explained.
“We thought we had to do something, as the patient was going downhill fast,” Michael added. “We didn’t think it could wait.”
“And you guys are medical students?” Hank asked. “I’m impressed. Have either of you rotated through the ER?”
Both Lynn and Michael shook their heads.
“I’m even more impressed,” Hank said. “Good pickup.” Then, turning to a nurse who had just entered, he said: “Let’s get a portable chest film stat and bring in a pack for inserting a chest tube.”
Hank turned back to Lynn and Michael. “Now, I’m going to have you guys insert a chest tube. Are you up for it?”