Chapter 3: Remember the Tiger
By the end of one month as an intern on the Trauma Gold team, perspective had become a deism-like entity; I knew it was out there, but I wasn't sure where or in what form. Immersed as I'd been in my cycle of efficiency punctuated occasionally with a sprint to the ED, I hadn't had much of an opportunity to consider the “why” of what I'd been doing. I was well-versed in the specifics of the primary survey (the A-B-C-D-E algorithm), but I had no idea who had first described it or how long it had been in use.
I'd grasped the basic structure of Sacramento's regional trauma system, but I didn't realize how nascent the coordinated care of traumatic injury actually was. If I'd done my residency training elsewhere, any glimpse of perspective may have indefinitely escaped me, but I was at UCDMC, home to Dr. William Blaisdell. I never met Dr. Blaisdell during my three years of residency; he'd retired from clinical practice some years before, but his legend was nevertheless inescapable. He was, I was repeatedly told in hushed reverence, one of the founding fathers of modern trauma care. Of course, it wasn't until after residency that I had a holistic appreciation of what this meant.
In the mid-1960s, when William Blaisdell became the chief of surgery at San Francisco General Hospital, coordinated responses to traumatic injury existed nowhere but on the battlefield. Back then, a gunshot victim such as Jeffrey Mains would have been treated much differently. A bystander calling for help wouldn't have dialed 9-1-1; that service didn't exist. Instead, he would have needed to thumb through the white pages to find help. Emergency phone numbers existed, but residents needed to consult the front of their phonebooks to find them, and there was great regional variability. In the eight counties of 1970s-era Kansas City, there were 78 different emergency phone numbers for 45 different ambulance companies.
Even if someone had figured out how to call for help, a victim such as Mains wouldn't have had access to a fully-equipped ambulance or paramedic team, and if he received transport at all, it would likely have been in a hearse, driven by one of the approximately 12,000 undertakers who supplemented their incomes by using their vehicles, sometimes converted for medical use, sometimes not, as transport for injured patients. During the ride, he wouldn't have received any treatment because most “ambulance” morticians worked alone and had no training in first aid. There would have been no radio contact between the undertaker and the trauma center either, and actually, no trauma center at all. Communication between rescue vehicles and emergency departments was about as standard as cruise control on a Model T. “Although it is possible to converse with astronauts in outer space,” noted the National Academy of Sciences in 1966, “communication is seldom possible between an ambulance and the emergency department it is approaching.”
Had Mains made it to an emergency department, he would have been treated by physicians with little or no training in the care of penetrating trauma and limited resuscitative resources. In this era, most of the doctors staffing emergency departments were not trained in emergency medicine and were interns or residents and working 24- or even 48-hour shifts. Jeffrey Mains would have, most certainly, died an unnecessary death. And in this respect, he would have had ample company.
Today, we know that about half of all traumatic deaths occur within minutes of injury. Most of these victims perish from massive hemorrhage or severe nervous system interruption. These types of injuries are untreatable; there is no meaningful therapy for a spinal cord pulverized by the high-speed collision of a head into pavement or an aorta ripped in two by the force of abrupt deceleration. The remaining half of traumatic fatalities occur minutes to weeks later, and can have myriad causes, including delayed bleeding, neurological dysfunction, infection, blood clots, and organ failure. Many of these subacute deaths can be prevented if injuries are recognized and treated in an expedited manner. Even in the 1960s, Dr. Blaisdell and his contemporaries knew this.
In 1965 alone, 107,000 Americans died from accidental injuries (49,000 in motor vehicle crashes), and trauma was the leading cause of death for those between the ages of 1 and 37. The resulting cost to the public in medical expenses, property damage, lost wages, and administrative costs was almost $18 billion. In today's era of inflated spending ($18 billion gets you a snazzy fighter plane or two), this sum may seem trivial, but at the time it was nearly equal to the government's annual appropriation for the Vietnam War.
The available evidence suggested that many of these deaths were preventable. For example, a 1961 survey of 782 traffic deaths in California found that accidents occurring in rural counties were almost four times more likely to be fatal than those in urban areas and that rural victims had significantly longer transport times and died of less serious injuries. Other studies, based on autopsy reports of highway fatalities, reported that up to 25 percent of the deaths were either definitely or possibly preventable. In some instances, the transport of accident victims was morosely backwards. In a highly publicized incident in Los Angeles County, morticians responded to a multi-casualty vehicle accident by first transporting the dead and then returning for the injured. Even those who received rapid transport to medical facilities or arrived in salvageable condition had a poor prognosis.
A review of seriously injured soldiers treated at civilian hospitals between 1957 and 1960 demonstrated that one in six died from potentially treatable conditions. The tragic irony for these soldiers was that they would have had better outcomes if they'd received their medical care from the military. Three major armed conflicts in the first part of the 20th-century had taught the military a great deal about treating traumatic injury, and death rates among battle casualties had declined significantly with each conflict: eight percent in World War I, 4.5 percent in World War II, and 2.5 percent in the Korean War. By 1966, military expertise was such that the National Academy of Sciences, in its landmark report Accidental Death and Disability: The Neglected Disease of Modern Society, stated that “if seriously wounded, the chances of survival would be better in the zone of combat than on the average city street.”
For William Blasidell, I later discovered, the impetus for change began in a different war zone, the Haight-Ashbury. In the mid-1960s, as the anti-war movement and counterculture burgeoned in San Francisco, so did drugs, and with drugs, drug-related violence. As chief of surgery at San Francisco General Hospital, Dr. Blaisdell's job included managing care in the ED, and beginning in 1966, he detected a dramatic increase in the violent byproducts of LSD and PCP-fertilized “flower power.” Between 1966 and 1968, the number of victims of violent crime treated at San Francisco General quadrupled, and by 1969 the rate of penetrating trauma was sevenfold greater than it had been 10 years before. With thousands of youths tripping on psychedelic substances, the inevitable daily assortment of bad trips further strained available emergency and psychiatric care. Dr. Blaisdell's emergency department, which was staffed primarily by surgical residents, was inefficient and overwhelmed.
In his historical account, Catastrophes, Epidemics and Neglected Diseases, Dr. Blaisdell recounts an illustrative case: “A patient with a complaint of ‘back pain’ was asked to sit on the bench and wait his turn until the woman he sat next to screamed and pointed to a knife sticking in his back.” Driven by the necessity to improve care for such patients, Blaisdell set about implementing the country's first city-wide trauma program. Toward this end, he was aided by the fact that San Francisco already had a single ED dedicated to receiving ambulance patients, San Francisco General's Mission Emergency, as well as one of the best ambulance systems in existence. While much of the nation was served by ill-equipped hearses without much in the way of communication or treatment capabilities, San Francisco had a fleet of ambulances with prescient features such as two-way radios, airway modalities, and room for multiple casualties, and they were staffed by “stewards” who were capable of administering basic stabilization measures.
Dr. Blaisdell coordinated with these ambulances to standardize the prehospital response, and created a dedicated “trauma team” to accept and manage patients. The squad consisted of an ED team staffed in 12-hour shifts by two interns and one resident who exclusively treated trauma victims and two ward (inpatient) teams with two interns and one resident each. The teams were supervised by a chief (6th year) resident who was on service (and lived in the hospital) for two months at a time and a rotating attending. In an era when residents in other specialties, according to Dr. Blaisdell's recollection, arrived to work in “sandals, tie-died T-shirts, and work pants” sporting “long hair, beards and mustaches, and love beads” and “judging from body odor [having] neglected to bathe,” these surgical residents were required to wear conventional white uniforms and maintain cleanliness. This dress code was emblematic of Dr. Blaisdell's attempt to institute a highly organized and militaristic approach to trauma care.
And in short order, he succeeded. In 1968 the San Francisco General Trauma Center was established with the goal of providing “immediate resuscitation and definitive treatment for all victims of injury.” The San Francisco model helped to spur others like R. Adams Cowley in Maryland, David Boyd in Chicago, and Blaisdell's protégé, Donald Trunkey to coordinate response to traumatic injury, and in 1972 the hospital became one of the first nine federally funded trauma centers in the United States.
A decade after establishing a trauma center in San Francisco, Dr. Blaisdell traveled 120 miles east to assume control of the trauma program at Sacramento General Hospital, which would soon become UC Davis Medical Center. From that day on, trauma care in Sacramento was done one way and one way only, the Blaisdell way. For the most part, Dr. Blaisdell followed established trauma protocols such as Advanced Trauma Life Support (ATLS). He had, after all, helped to develop them. There were, however, certain idiosyncrasies, one of which I witnessed on the first day of my trauma internship. I recall standing in the back of the trauma bay having arrived a minute later than the patient and feeling completely useless. Two other interns had already brandished their trauma shears, and were at work on denim pant legs. A somewhat tentative junior resident with a prominent hook nose was assessing the A-B-Cs, and had just reported the blood pressure and moved on to D (Disability) when his senior barked at him, “Check the belly.” The junior looked up with submissive confusion and then complied, pressing on the patient's rotund midsection several times before declaring “abdomen soft and non-tender.” I, too, was confused; I had dutifully studied the ATLS guidelines and was pretty certain that an abdominal exam was not part of the A-B-Cs but rather of the secondary survey that followed them. This may not seem like a significant difference, but remember that trauma resuscitations nowadays are extremely regimented and deviations from the protocols are not usually tolerated. The ED attending must have noticed my questioning gaze. He leaned over to me, and said, “That's how Blaisdell always wanted it done.” Then he added, “Blaisdell loved the abdomen, loved it.”
Indeed, it was true. Dr. Blaisdell had exhibited a long-standing passion for the abdominal exam, and believed that it should not necessarily be restricted to superficial means. “Laparotomy is the natural extension of the abdominal exam,” was a famed Blaisdell justification for rushing a trauma patient to the operating room for surgical exploration. High resolution CT scans had given Blaisdell disciples another diagnostic tool that could be used in lieu of surgery to evaluate patients with suspected abdominal injuries, yet they continued to respect Blaisdell's deviation in the primary survey. As the intern in charge of Foley catheters and warm blankets, I concluded that it was not my place to point out the discrepancy. Nor did I ever assail the necessity of including a manual rectal exam with every trauma's secondary survey. Fortunately for me, this job belonged to the second-year resident, but I still often winced at the uniformity with which it was administered, even to patients who had isolated or superficial-appearing injuries. Out of earshot, we referred to this intrusion as the “UC Davis handshake,” and it was sometimes unannounced, or even worse, announced incorrectly. I once overheard a resident tell a patient, “Sir, now you are going to feel your finger in my bottom.”
The battery of trauma laboratory tests, called a rainbow because it utilized every possible color of collection tube, performed on virtually every trauma patient also puzzled me. Was it really necessary, I wondered, to check clotting studies in healthy young people or obtain an alcohol level in an 8-year-old boy? Not everything we did made sense to me but, like the other interns, I trusted the prevailing wisdom of Dr. Blaisdell and his disciples. Eventually, it dawned on me that their treatment protocols were designed to limit the critical thinking of the young doctors who implemented them. If things were done the same way every time, nothing would be missed. If selective judgment was used, in particular selective intern judgment, something might be overlooked. For a while, this presumption that I was not to be trusted to make clinical decisions irritated me, but this was because I was looking at it from an individualistic rather than a systems viewpoint. In reality, there was no need for me to make clinical decisions when well-established protocols could make them for me. In those situations in which the protocols didn't have the answer, we turned to Dr. Wisner.
The surgical residents referred to Dr. David Wisner as “The Wiz,” a tribute to the breakneck speed at which he conducted morning rounds. Like the others, I was impressed by his ability to make rapid clinical assessments and decisions but even more impressed with the quiet authority he exuded. Surgeons are often portrayed as brilliant but volatile characters, always on the edge of ripping into a subordinate who isn't getting it quite right. Not Dr. Wisner. His voice was soft and reserved, yet somehow it carried a hundred decibels worth of strength. His physical presence was undeniable, he was as stout as ironwood, but there was something more. During many trauma resuscitations, he would stand silently in the back of the trauma bay, letting the fellow or senior resident run the show and occasionally providing guidance with gentle queries. As soon as a resuscitation went off track or became chaotic, however, he took over. “OK, everybody, I am running this code,” he'd firmly declare. “Anyone who is not doing anything here needs to leave this room.” Whenever he did this and the huddle of gawkers dissipated, it set me at ease. No matter how sick our patient appeared, Dr. Wisner had the situation under control. I have no doubt that Dr. Wisner's mentor, William Blaisdell, had in his day demonstrated a similar aura of calm leadership.
Although Dr. Wisner had been chief for some time, he still honored many of his mentor's traditions. Like Dr. Blaisdell, he often jogged the stairs during morning rounds, sometimes up seven flights straight, a ritual that occasionally (and one might say, predictably) caused a sleep-deprived resident to pass out. The two trauma services, the Blue and Gold, were named after the two separate surgical services Dr. Blaisdell had established at San Francisco General in 1968. Dr. Wisner's Socratic teaching style was straight from the Blaisdell playbook, and while this rarely surfaced when we whizzed through rounds on the (mostly uncomplicated) patients, it was clearly evident in other forums, such as his lectures to residents and students. Dr. Wisner also continued the Blaisdell practice of using fictional situations to teach important surgical principles. The story I recall best is that of the tiger.
“That was classic Blaisdell,” Dr. Wisner later explained to me. “He would start out by asking all of us, as he peered through his black horn-rimmed glasses, ‘Why is it dangerous to shoot a tiger?’ Those who hadn't heard the story before would fumble and stammer, trying to answer, not having any idea what he was talking about. The answer was that if you shot a tiger, a muscular tiger with layers of tawny flesh rippling under its fur, that you couldn't track it because it wouldn't bleed. The overlying fur and skin would cover up the wound and that tiger might be bleeding internally, but you would have no way of knowing unless you captured him or he died. Dr. Blaisdell would have us all going, picturing ourselves hunting down a tiger in an Asian jungle. Maybe the tiger's hurt, maybe not. And when you weren't looking, the tiger would jump from a branch and eat you. Then he'd look at us sternly and tell us to always remember that in a trauma, you couldn't tell by the wounds on the outside what was hurt on the inside. Remember the tiger.”
Thinking back to the day that Jeffrey Mains was discharged from the Trauma Nursing Unit, I am reminded of Dr. Blaisdell's proverb. By then, Mains’ external wounds had mostly healed over, and scarred as he was, it was impossible to tell from the outside the extent to which he was hurt on the inside.
For 23 days, Jeffrey Mains had been a resident of the second floor SICU, and he'd remained in critical condition throughout. Dr. Wisner repeatedly told Jeffrey's mother, Linda Mains, that he was not optimistic that her son would recover. “I don't think he ever really gave up on Jeffrey,” said Linda Mains, “but he didn't want us to expect too much. It was like that for 20 days.” On Sept. 17, Mains returned to the operating room for re-exploration and to have multiple abscesses drained. He was back in the OR on Sept. 27 to have the fluid collecting in his lung removed by video-assisted thoracic surgery. Afterwards, Mains developed an enterocutaneous fistula. He was on multiple antibiotics, multiple pain medications, received his nutrition through IV fluids, and hadn't had a normal bowel movement for more than two weeks. Although now awake and alert, Mains still had difficulty speaking because of residual tracheal swelling from where the breathing tube had been and was unable to use his (dominant) left arm because of a painful blood clot. Understandably frustrated, he barely even attempted to communicate.
Even as preparations were made to downgrade Mains’ care to the Trauma Nursing unit (TNU), an ominous cloud seemed to hover over him. But on that 23rd day in the SICU, that cloud thinned as four words were scrawled on a piece of plain white paper. With an unsteady right hand, Mains wrote a simple message to his family, “We will make it.” For Linda Mains, this was the point where cautious optimism turned to belief, belief that her son would someday go home and that the essence of his character was intact. “Jeffrey is such a gentle person,” she later told me “and he never wants to impose on others. It wasn't about him; it was about us. He didn't write, ‘I will make it.’ No, it was, ‘We will make it.’”
But Mains’ recovery wasn't as simple as four scribbled words; in fact, things would get worse before they got better. For days after being transferred to the TNU, Mains slouched on his bed, looking gaunt and defeated. His pain was difficult to control, and he didn't want to walk. In fact, he could barely stand because of the tension from his abdominal scars, and he had to be coaxed to take sips of fluid. His blood tests were still abnormal, he was anemic, and his body's white blood cell count was double the normal value, indicating that he was still fighting off infection despite being on two strong IV antibiotics. Slowly though, spurred by his family's encouragement, he progressed. A physical therapist forced him to get up and move, teaching him, step by step, how to walk again. One evening he was brought a large tray of food — lasagna, salad, and more — laid out on a tablecloth in front of his hospital bed. He kept the meal down, but it didn't stay in his system for long. “It was like my innards were brand new,” he later recalled. Over the next few days, supplemented by a steady diet of Jamba Juice smoothies, those remodeled innards began to function again.
The psychological improvement was less steady, and Mains had frequent episodes of acute anxiety. He repeatedly relived the moments before and after the shooting. Pulling up to the stoplight in his truck, the commotion, the sound of shots ripping through metal. The realization that he'd been shot. Stepping out on to the road. Collapsing. Conscious one moment, blackness the next. Restrained and groggy in a strange room with beeping lights and pictures of planes flying into buildings on the TV. Twenty-three days in the SICU.
Mains saw a psychiatrist, who on Oct. 18, wrote the following: “Mood anxious with tearful affect. He has felt very sad and anxious, cries all the time, can't sleep more than three hours at night; has recurrent thoughts about the shooting, is hypervigilant and jumpy. Also, feels depressed to the point of not wanting to do anything.” Based on these observations, Mains was diagnosed with acute stress disorder, and started on a trial of Valium.
“It was the saddest time,” said Linda Mains. “It was always sad, but now he was cognizant of the pain, and of the situation. It was a tough time in that trauma unit.” Mains no longer had a room and a nurse to himself, and he saw less of Dr. Wisner and more of inexperienced interns like me. And as he began to eat and walk again, it got worse. His mom remembers him as “constantly sobbing” and “just unable to pull it together.” He was also becoming angry, and no one blamed him. Chance had played him a wicked game, put him in the path of a maniac with an arsenal of weapons, and he had the right to be pissed off about that. “How did that kid get a weapon like that?” he once asked me. “An AK-47, an automatic assault rifle. In the middle of Sacramento, just shooting people.” Everyone agreed that it was time for Jeffrey to go home; surely the emotional recovery would be faster there because it was going backward in the TNU. On Oct. 24, we removed the last remaining intra-abdominal drain, took out the IV, packaged up some dressing supplies for the remaining open abdominal wounds, prescribed more than 100 pain pills, and sent Jeffrey Mains home.