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The Procedure

Robert Brandt’s riveting story of an E.R. resident trying to save the life of a teenager took this year’s grand prize.

With the emergency room’s lights beaming down, I reach into the gaping hole I made in the side of her chest. The incision, 20 centimeters from under her nipple, following the rib-line all the way down to the table, has an appearance usually seen in murder mysteries. Reality, however, grips so hard that breathing through my mask is difficult. I slowly, yet forcefully, push her deflated lung upward to provide better access and visualization of the heart. This procedure makes onlookers squeamish, and the spectating medical student leaves the room. I look inside and see the heart struggling in a battle against the fluid filled pericardial sac.

The thoracotomy stands alone as the ultimate heroic intervention for any new emergency medicine resident. The older docs know better than to be excited. Such heroics never work, they have repeatedly told me. Screw them; this is cool. I may only be a second year ER resident, but I will not give up without trying. I cross-clamp the aorta so that blood can not flow down to the lower body, only up to the brain, lungs, and heart, to keep the vital organs supplied.

I peer inside the bloody chest cavity and gently cradle the heart with my sterile gloves. I feel it struggling in my hands like a fish in a water-balloon. The balloon is the pericardium, a tough fibrous sac that encases the heart. The heart (the fish inside the balloon) wiggles in my hands, trying ineffectively to pump against the fluid. Scanning franticly, I locate the phrenic nerve. This tells the diaphragm to keep functioning and filling the lungs with air. Cutting the phrenic nerve is considered bad form.

“Scalpel.” I say. A scalpel appears in my palm.

I nick the pericardium to release the blood from the sac around the heart. The blood drains quickly into the thoracic cavity. The fish in the bag now pumps more efficiently. I watch the blood pressure monitor… Maybe some pressure has returned. I wait.

A large puddle of blood starts to coagulate at my feet. I did not notice it dripping off the side of the bed, into my scrubs and shoes. A puddle? I can feel the warm blood oozing into my right sock. I wait. The blood no longer is completely liquid, but has become gelatinous on the ground and on the table.

I glance again inside the chest cavity. I peer like a mechanic staring under the hood of a foreign car hoping that the broken part will scream “fix me!” For a split second, the entire room is quiet.

I watch her heart beat. I have seen it only one time before in a coronary bypass surgery. That situation is calm and controlled; here, the patient’s vital signs go from mediocre to complete crap instantly. A nurse feels her neck, willing it to have a pulse, any sign of blood movement. I wait an eternity, ten seconds. The monitors still show nothing.

CPR is continued. I reach inside her with both hands and start manual compressions of her heart. Squeeze. Squeeze. Squeeze. I can not really believe that I am doing this.

All the residents talked about this in procedure lab, where we first learn how to do our procedures. I remember cutting a towel-wrapped laundry basket, pretending it was the ribcage. We had practiced in stations, rotating and joking. What was the heart in that practice lab? I think it was a Nerf-ball inside a plastic bag. Squeeze. Squeeze. Squeeze. When was I supposed to start squeezing the heart? Was it right after I got it out of the pericardium? Too late to worry about that now, isn’t it? How long since we started? Squeeze. Squeeze. Squeeze.

I visualized the procedure I had just performed. I remember the long skin cut. I remember inserting the vise-like devise to spread her ribs apart. I see the ribs bending as
I twisted the opening vise, making the hole between her ribs wider. The horrible crunching sound remains vivid. Each turn I can hear her ribs groan in protest, bending bizarrely. It is quite hard to replicate that crunching noise in a practice lab. Squeeze. Squeeze. Squeeze.

The ability of the heart to beat on its own has long since dissipated. I feel a hand on my shoulder and see one of the attending emergency physicians looking over. I glance up at the clock. The time really means nothing to me since I have forgotten when the patient actually arrived. How long has it been? Squeeze. Squeeze. Squeeze.

“How long has it been?” I ask.

“Forty-five minutes,” a nurse replies.

“Oh,” I say, trying not to let the overwhelming disappointment percolate through my voice, but defeat emanates through me.

I know it. Everyone knows it. Perhaps the old docs knew it before I started. I know the odds, I know the chances, I know… well, I know. She is dead.

I stop. I try to breathe deeply and evenly, but I can feel chaos still dancing around the room. What just happened? A 16-year old girl got shot, and I tried to save her. My hands squeeze the air a few times, not feeling the girl’s heart between my fingers. Breathing seemed hard.

“Stop CPR. Time of death,” I look back up at the clock. It is 11:03 PM. Somewhere people were up late watching cartoons and eating popcorn, or playing poker with buddies, but here a 16-year-old girl had just died. It felt so weird that I had thought about cartoons the second before pronouncing a death. “Time of death, eleven oh-three.”

I take a step back from the table. My heart races and the adrenaline I did not realize was pumping continued to surge. I realize my hands have started shaking, and I continue staring at the opening in her side as I slowly walk to the garbage can. Why am I at the garbage? I sigh. I strip off my sterile gloves and blood-spattered gown. Thank goodness they were sterile. I would not want to get any bacteria into the giant gaping chasm in the side of her dead body. I sigh again and take another deep breath. Damn, only 16? She probably watched cartoons herself.

I glance over at the nursing station. A friend of mine, another resident, jokes with a nurse and both had expansive grins on their faces. They have no knowledge of this case, or of my shattered dream of heroics.

I could still feel it, right when I opened her heart from the pericardium, it was beating, she still had some life. Her heart did, at least.

I walk out of the room. I can feel the squish in each step where her blood had drained into my shoe. I walk downstairs to the changing room and sit down. The coolness and quiet envelop me. I still need to talk to her parents, to dictate a note, to review her case, to know every detail about what has just flown by in an instant and try to make sense of it in my mind. But for now, I sit. I sit quietly. I feel nauseous. I feel terrible. I feel empty. I feel my pulse. It races through me. I feel throbbing in my head. I take a deep breath. The deep breath does nothing. The door opens.

“You know, you really did great up there.” It was my senior resident. Obviously I did not do everything alone, but they allowed me to do the procedure that many residents in their ER training never even get to see.

“Yeah,” I replied. I had nothing. Empty. Hollow. Hole, not whole.

“Take a break, man. You want me to close the laceration in room 14?” he asks. He sits next to me for a long twenty seconds, either not knowing what to say, or knowing to say nothing. My mind finally catches up to what he said to me.

“Oh. No thanks, I’ll get it,” I reply.. Somewhere,t housands of miles away, upstairs in the emergency department, I had started seeing a different patient. I had interviewed another kid before the radio announced a priority one code coming in. I took a history and physical about child who had a small cut on her forearm. I paused in thought. I had been seeing a patient before I cut a gaping hole into a 16-year old girl’s side and squeezed her struggling heart in hope that she could live.

Before the thoracotomy I saw a 9-year-old with a cut that needed stitches. She still had to be treated, and the ED keeps going. I take another deep breath and stare at the blank wall. Five minutes pass. Time to go back to work. Time for another procedure.

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