First Day On the Job

Progress Notes
A Scared and Sacred Silence

Monica Kidd, BSc, MScMedscape Med Students. 2009; ©2009 Medscape
Posted 01/14/2009

It was just past lunch on my first day in the hospital. I was getting my tour of the facility before getting my passwords for the computers. We were passing through the emergency department when a consulting doctor said to me, “You want to jump in with both feet? There’s an MVA [motor vehicle accident] coming in right now. One victim’s in, another 2 en route.” I had just learned of a patient I had to see in emergency who’d already been waiting nearly 12 hours; there were a couple of histories and physicals to do upstairs; and the surgeon I’d been working with in the morning was expecting me back in clinic, but what was I going to say, “no”?
I saw the mom: 33 years old, the driver of the vehicle, belted. She had 3 kids in her car — her 2 sons and a friend of theirs. She was turning right onto Magee Road, just across from the hospital, when a transport truck T-boned her, setting off the airbags. The examination was difficult because the whole time she kept asking about her son, R, and I had to honestly say that I didn’t know his condition; I didn’t even know which boy he was. One of them, in the first trauma bay, was not doing so well; another in the trauma bay beside him seemed fine.
“Do you know what day it is?” I asked. “Two days before my little boy’s ninth birthday,” she wailed. Besides a bump on the knee and some abrasions from the seat belt, she was physically fine. When I finished with her, I saw the third boy, the one who’d been riding beside her in the front passenger seat. He was okay, too, except for some aches and pains. Word trickled down from the first trauma bay that the boy would need to be medevaced to neurosurgery in St. John’s.
Having settled those two away, I saw my patient with the small-bowel obstruction and talked about him with the surgeon on call. I decided that clinic was a blowout, and went upstairs to do my histories and physicals. I finished the first — a woman in her 70s, admitted for a hemicolectomy for colon cancer in the morning — and was about to begin my second when the charge nurse on surgery took a call.
“You know that MVA?” she asked me. “It looks like he’s not stable enough to fly. Dr. Haggie’s going to take him to the OR [operating room].”
I wanted to go, but having missed out on my tour of the hospital, I didn’t even know where the OR was yet.
I left the second history and physical and went back down to emergency and found the senior resident in the middle of inserting a chest tube in the little boy, whose eyes were partially open but not focused on anything. He was intubated, and a blood transfusion was under way. He looked pale. Several nurses whirled around with flushed faces.
A man in scrubs came through the curtain and said to me, “You must be the intern!” and immediately began a play-by-play of what was happening. The charge nurse said something to the effect of getting the boy’s parents in so they could kiss him good-bye. They were brought in on uncertain feet, the mother still firmly in shock. The dad, rugged and tanned from some kind of outdoor work, kissed his son and stood back to cry.
Into the OR: an emergency laparotomy for a ruptured spleen, diagnosed on computed tomographic (CT) scan. The senior resident was busy speaking to the pediatric surgeon in St. John’s about accepting him in transfer. Looked like it would just be Haggie and me. I scrubbed and came back in to find draping already under way. Surgery would proceed with the boy still on the spinal board and in his cervical collar.
I felt his rigid abdomen. Haggie made a fast midline incision from breastbone to pubis. The blood began pooling in angry eddies, spilling over his sides and onto my shoes, wetting my feet. Haggie reached in and cut the spleen from the mesentery, “delivering” it to where he could identify the vessels. He clamped and cut them, removed the spleen, and showed me the multiple fracture lines. We tied off the vessels, and then he began to explore, moving quadrant by quadrant, sponge in hand, packing and unpacking — petechiae in the mesentery and over the retroperitoneum, signifying either massive trauma or disseminated intravascular coagulation. No perirenal and periaortic hematomas that he could discern. No damage to the bowel — but still the blood kept coming.
The senior resident arrived, mumbling some rather unflattering comments about the surgeon in town. I took my place over by Haggie, who extended the incision to the xiphoid and handed me a retractor to pull up on the breastbone so that they could examine the liver. A laceration to the capsule. First, they tried cornstarch and cellulose, plus holding the liver against the diaphragm to apply pressure. That didn’t work. They tried pressure with a sponge on a stick. That didn’t work. The suture material Haggie wanted wasn’t around, so he ordered up a graft that is normally reserved for vascular surgery. Meantime, we waited. He handed me the sponge on a stick, so I held that in one hand and the chest retractor in the other, and held on until I could feel my pulse throbbing in both hands. The boy’s little heart, fighting against the constant loss of blood, pumped away against my tools, so that our 2 pulses beat out a strange syncopation.
Soon the patient’s blood pressure fell into the 30s and then into the 20s. The anesthetist, constantly frowning, tried more blood, epinephrine. The heart rate rose and fell. The oxygen levels began to slip away. The abdominal bleeding seemed somewhat under control, but somehow he still was losing massive amounts of blood. The chest tube was patent, but no more blood had drained. They tried another chest tube in the left chest, wondering about a tension pneumothorax, but nothing happened to his oxygenation levels.
Finally, Haggie made the call. “Let’s get out. Let’s get him to the ICU [intensive care unit] in time to let his parents say good-bye.” The senior quickly closed as Haggie went out to speak to the family.
I backed off and watched the boy’s vitals. I took off my sterile gown and gloves in anticipation of the walk to the ICU. The nurses debated how best to present the boy to his parents — not on a white sheet, because that would show the blood. A hematoma on the back of his head had grown alarmingly. Blood came from his nose and ears and filled the endotracheal tube. The nurses wiped him down as best they could, removed the blood-soaked tape from his eyes, and the endotracheal tube from his mouth. I looked at his little hands and lips, now turning blue. His pressure metronomed between the 20s and 40s. Things seemed to grow very quiet as the little boy hovered in the infinite space between living and dying.
Out we went to the ICU. The critical care nurses began a dopamine drip and put on chest leads. A nurse in plain clothes said, “What a beautiful little boy,” and walked out to get his parents. I began wiping tears from my eyes. Haggie arranged blood work and admission orders with the staff. The senior resident began to shake his head slowly.
The mom and dad came in, and the mom began to shake. “Don’t leave me yet. You’re momma’s little boy.” And with that, I left to find a quiet room in which to let go my sobs.
In the days to come, an army of teddy bears would be taped and tied to a light pole near the intersection where the accident happened. I would pass it every day on my way to and from work, a constant reminder of that scared and sacred silence into which R slipped under the lights of the operating room.

Monica Kidd, MD, MSc, first-year resident, Memorial University of Newfoundland, St. John’s, Newfoundland and Labrador, Canada

Disclosure: Monica Kidd, MD, MSc, has disclosed no relevant financial relationships.

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