Blood ran down his arm and dripped off his hand.  It was more like a stream than a drip, a steady flow forming an enlarging puddle on the floor.  That was all I could see of him at first.  There were people huddled around him, in yellow gowns, all frantically doing something, or yelling for someone else to do something.   I crowded through the chaos to the head of the bed and looked him over.  His hair was a mess of blood mixed with chunks of some type of food.  An overwhelming smell of stale beer and vomit filled the air.  Dark dried blood caked his left ear, and a large gash across his forehead went down to the bone.  His eyes were swollen shut, barely visible as most of his face was enveloped by a large mask.  A respiratory tech was busy bagging him, forcing air into his lungs.  He was immobilized in a cervical collar and strapped to a back board, with bright orange foam blocks stabilizing his head.  The left chest was grotesquely misshapen, crushed inward.  Every time the tech squeezed the oxygen bag, I could hear a gurgling sound and bloody fluid bubbled out of a wound under his torn shirt.  His abdomen was very bloated and distended.  Despite a splint that was encasing it, one leg was bent at an awkward, impossible angle.  I glanced around the trauma bay.  No other surgery residents were here yet.  It was just me.  I felt a cold sweat break across my brow. 

“That’s the new surgery intern,” someone said in a whisper.  The room quieted, and all eyes turned to me.

     Five minutes ago, I had been sound asleep in my call room.  It was about two am, and I had managed to get to my bed about forty-five minutes earlier.  My sleep was interrupted by my screaming pager, announcing “TRAUMA ALERT, EMERGENCY ROOM!  TRAUMA ALERT, EMERGENCY ROOM!”  It was my second time on call as the new surgery intern, my first week of being a real doctor.  I fumbled for my glasses, grabbed my white coat, and stumbled down the steps, out into the dim little parking lot.  I hurried across the lot and through the back door of the ER, my mind racing.  I thought, this is it.  This is a real trauma. This is a real person who needs help.  I might be the first one there, and if I don’t do everything right, maybe they’ll die.  I hope someone else gets there quick, because I don’t know for sure what the hell I am doing, and I don’t want to kill someone during my first week.  Then I started thinking about the ATLS (Advanced Trauma Life Support) protocol – it’s so simple.  ABC – Airway, Breathing, Circulation.  These are the first things you attend to in a trauma patient, you really don’t even need to think much about it.  Intubate if you need to, get the patient breathing, put chest tubes in for blunt trauma, get some big IV’s started and give fluid.  I can do that, and by the time I have done all that, someone else will be there. 

     I had been to many traumas as a medical student, but this was different.  As a student, you just do what you are told, mostly standing in the background, keeping out of the way.  Maybe you’ll get to hold a light for the resident, or help cut the clothes off, or if you are really lucky, maybe draw some blood.  There are expectations to participate in patient care, but no real responsibility.  There was always a resident there, who seemed to know so much more than I did and seemed to be so confident.  But now I was the one with M.D. behind my name, and suddenly I would be the one making decisions and taking responsibility for someone else’s life.  I felt a mixture of ominous dread and eager anticipation, half wanting someone else to be there and take care of everything, half wanting to prove that I could do this myself.  

     Standing at the head of the bed, with everyone looking expectantly towards me, I disconnected from the visual image of the crushed human being that lay in front of me.  I heard myself saying “What’s his oxygen saturation? Pressure? Who brought him in?  What happened?”  I got simultaneous answers, none of them very encouraging.  He was the intoxicated driver, no seatbelt, in a rollover motor vehicle accident.  The passenger died at the scene.  The patient was conscious initially, but extrication from the vehicle took thirty minutes.  He became unresponsive in the ambulance, and they had administered IV fluids, but his blood pressure had dropped to fifty, dangerously low. 

     The nurse told me his oxygen saturation was sixty percent, and his pressure was too low to measure.  The ER doctor was working on getting a large catheter into the femoral vein to give more fluid and blood quicker.  I barked at the two medical students to start cutting off the rest of his clothes, and proceeded to do my first emergent intubation.

     His throat was full of thick vomit, and I couldn’t see anything.  Because he was strapped onto the back board to protect his spine, we couldn’t move his head into a position to make intubation easier.  Where the hell was an anesthesiologist?  They were the experts at this, and should have responded to the trauma.  Why weren’t they down here to intubate?  Someone had mentioned that an emergent Ceasarean section was going on, so anesthesia would not be down for a while.  I could feel the cold sweat dripping down my back.  Airway, the first step in the protocol.  If you can’t secure the airway, nothing else matters.  It only takes a few minutes for the patient to die from lack of oxygen.  I couldn’t see the vocal cords.  I couldn’t see the entrance to the airway to get the tube into the right place.  I couldn’t even tell where the base of the tongue was for sure, there was so much debris in his mouth.  I knew if I could not get the tube into his airway in the next few minutes he would die.  From beside me, a gloved hand reached in and scooped a handful of debris out of the mouth, followed by a suction catheter and a bright light. 

“Just pull up harder on the blade and shove it in there.” 

     It was the respiratory tech, who had probably seen this done about a million times, and could likely have done a better job than me.  I did what I was told, and he put some external pressure on the larynx, and the vocal cords came into view.  I watched the tube glide between the cords into the trachea. 

“Okay, I got it from here,” he said as he hooked the tube up to oxygen and continued bagging. 

Airway – done.  Next – breathing.