Surgery residents learn a lot about what goes on in America between midnight and 4 am. Serious injuries resulting from bar fights, cars wrecks, and gunfire are usually treated by surgical residents at trauma centers. One summer evening, I was the resident on call at a Level II trauma center. Around midnight, I escaped to my call room and slipped off my shoes. The cool air soothed my feet. As I lay down, the crackle of the plastic mattress cover reminded me that this bed was not my own and my sleep would be interrupted. As my eyes closed, the trauma pager went off.
When I arrived at the trauma bay, CPR was in progress and the blood soaked clothes of a lifeless man were being cut off under bright lights. The blood loss and absent blood pressure suggested hypovolemia. The only obvious injury lay beneath a bandage on his right arm. He was found with a window-type air conditioner at his feet. It was not clear whether he had been trying to install it or steal it.
The seasoned ER nurses were unable to place peripheral IVs. I grabbed a central line and felt the right groin for a pulse. There wasn't one. “Fire up the Level One Infuser with two liters of crystalloid which we'll chase with four units of blood. Tell the blood bank we need more blood,” I said, hoping that someone was listening. As an intern I had progressed through the “see one, do one, teach one” sequence of learning to place central lines in controlled settings. This scenario added a level of difficulty. “Hold chest compressions,” I said without diverting my eyes from the task. The needle had found the femoral vein, and soon the line was in place. The rapid infusion of volume restored his blood pressure. A quick look beneath the bandage on his arm showed pulsatile bleeding. I reapplied the pressure dressing and said, “Call the operating room and tell them we're coming.”
As we left the ER, Dr. Sullivan, the 65-year-old attending surgeon-on-call with me, arrived from home. I told him the story. “How come you're not in the operating room yet?” he asked, only half-kidding. Ten years earlier Dr. Sullivan had given up a lucrative private practice for the less tangible rewards of teaching residents, caring for the uninsured, and enjoying the vagaries of trauma call. His greatest asset as a surgical mentor is the example he sets for the residents. He's always polite, altruistic, and does the right thing for his patients. His enthusiasm for working as hard as the residents when he could be retired is a testament to his motivation for becoming a general surgeon in the first place.
Dr. Sullivan and I spent the next two hours repairing the patient's injured brachial artery. We harvested a saphenous vein from the patient's thigh, and interposed it between the injured ends of the artery. The challenge of performing a technically demanding case in the middle of the night made me forget that I was awake while my family and friends were sleeping. If only they could know what they were missing. We finished the case at about 6 am. I washed my face, got a fresh cup of coffee, and began seeing patients. At some point, I began to wonder if the trauma patient's brain might have gone too long without oxygen during the resuscitation. Later that day, however, the patient began to wake up, and was soon extubated. He was transferred to the floor the next morning, and went home four days later.
During residency training in general surgery, you give up and put up with a great deal. From time to time, however, you make a real difference in the lives of your patients. This translates into a handsome return on your investment.