We simultaneously moved him from the paramedic’s stretcher to the ER gurney, hooked him up to monitors, got another IV in his arm and started administering IV fluid.  The nurse was already opening the chest tube set.

     Breathing.  There was no air movement in his left chest.  I needed to put in chest tubes to relieve a possible collapsed lung or drain blood so the lung could expand.  I dumped some betadine on the skin and made a deep one inch cut on the chest wall, digging through the muscle to find the ribs.  As I pushed through a thick layer of intercostal muscles to get into the chest cavity, I heard a sickening crunching sound as fractured pieces of rib grated together.  My blunt clamp popped through, into the pleural space surrounding the lung, and I pushed the tube into the chest.  A projectile stream of blood shot out the other end of the tube and sprayed about four feet behind me.  He was obviously bleeding into his chest.

“Listen, genius, next time clamp the end of the tube before you put it in.”  Tad, the SICU (Surgical Intensive Care Unit) resident, was placing a clamp on the open end of the tube, stopping the flow of blood. 

“But look on the bright side, you got it in the right place,” he continued.  Tad seemed totally relaxed and calm.  I felt a wave of relief.  Thank God, someone else was here.

     He proceeded to place the other chest tube and we hooked them both up to suction.  After that initial spurt of blood, not much more came out of the chest.  We continued giving large amounts of fluid and blood through a big catheter in his femoral vein, trying to keep up with what he was losing.

“Heart rate is forty.  Heart thirty….twenty-five.  He’s going to flatline.”

     Tad called for the nurse to give some atropine, then epinephrine.  He took a long needle and slid it under the patient’s sternum, aiming to get into the pericardial sac around the heart.  If there was a collection of blood trapped in the sac around the heart, draining it with a needle could buy us some time to get him to the operating room and fix the problem. Blood in that space could constrict the heart enough that it couldn’t beat effectively.  He didn’t get any blood back.

“C’mon, Carol, this is your chance to do a DPL.  I guarantee it’ll be positive.  Get the stuff,” Tad told me.  A DPL, or diagnostic peritoneal lavage, was a quick procedure to find out if someone was bleeding internally.  I would make a hole and feed a thin little catheter into the abdomen to see if it was full of blood.  He would need to go to surgery to open his abdomen and try to stop the bleeding if we found blood.

     Tad continued giving orders and I made my incision above the belly button, digging down through the fatty tissue under the skin, trying to find the layer of fascia. 

     Dr. Zayed, my senior surgery resident, had just walked in.   The patient had completely lost a pulse and blood pressure. 

“Clear!!!” someone yelled, and we all stepped away from the table as Tad held the defibrillator paddles against the chest and delivered the shock.  The patient’s body jerked up, then relaxed.  An ER nurse jumped back in to continue CPR and check pulses.  Between shocks, I was continuing my struggle to get the catheter into the free space within the abdomen.  I had become consumed by this task, almost forgetting about the code going on around me. 

“Oh, c’mon, Tad, what are you doing?  This guy is dead,” Zayed said, looking at the flatline on the monitor.

“Well, he wasn’t dead ten minutes ago.  I’ve got to at least let Carol finish her DPL. If we can keep this guy alive for a week, she might actually finish.”

     We had been coding him for almost twenty minutes, with absolutely no response.  He had no heart rhythm, and no detectable blood pressure.  Dr. Zayed got on the phone to the chief resident, and told him not to bother coming in, the guy was dead.

     We called the code and pronounced him dead.  Very quickly, the room emptied and became quiet.  The patient lay still on the gurney, naked, with tubes coming out of everywhere. His arms were dangling off the sides, big IV lines in place.  He had an unnatural bluish grey cast to him.  Blood was on the sheets, the floor, even the wall behind him.

“Finish that, you need the practice.  Next time, it might matter, so you need to learn how to get it done quicker,” Tad said as he helped me get the DPL catheter positioned.  A steady stream of blood drained out.  

“A belly full of blood.  I bet he smashed his liver, or tore it off the cava.  Nobody survives that,” Zayed said as he left. 

“Fill out the death certificate and go talk to the family,” Tad instructed.

“Me?  Oh, uh…what do I say to them?” I stammered.

“Say he’s dead.  You’ll figure it out. You’re a real doctor now,” he answered.