I’m an OK surgeon now but almost never got a chance, since I nearly got fired as a resident.
22 y.o. AA male GSW x 3 to the back. CXR with maybe some haze in the LLL. Lines placed. O2 mask on, tachycardic but who wouldn’t be? I’m zoned in on a couple of sketchy B.P.’s, hemodynamic instability in the setting of penetrating injury to the back being an absolute indication for laparotomy. The bullets couldn’t have hit the aorta or an iliacs, if so the guy would be dead by now, so I’m thinking low pressure retroperitoneal injury? Renal vein? Spleen? Something in zone III? a mesenteric vessel? ****. New, young ER attending in a white button down oxford shirt and a tie wants to put in a left chest tube. Massive hemothorax ain’t the problem, the volume of blood that you would need to give you hypovolemic shock parked in the thorax won’t give you that x-ray but whatever, my PGY2 he needs the practice, so I tell him to prep.
It’s more than the usual degree of chaos, even for 1am at Luke’s. The guy had been shot by the cops so blue waves keep crashing into the trauma bay door requiring regular dispersement. Not that the cops give the impression of actually giving a ****, it’s December of 2004, Ferguson is a decade away and this was in the days when cops still shot young black guys in Harlem because it was part of their job description. Still they were curious to see just what type of paperwork was going to have to be filled out. Patient himself seemed to be opting for the form that didn’t have a time of death on it. The lad is definitely showing bit more spunk than you would expect from someone en-route to his reward via exsanguination but sometimes they can fool you. The other guests to the party were some nurses, my team of exhausted pissed-off surgical residents wishing they were anywhere except responding to a trauma call with me as the chief, and the ER team, maybe six of them all delighted for a distraction from asthma attacks, UTI’s and drug seekers, hoping to see something like on TV and lead by that tense looking attending in the white button down oxford and tie, looking like a guy from NASA in the 60s.
Oxford shirt dude is now standing at the foot of the bed, Pete’s on patient’s left giving some lidocaine at the 5th intercostal space and posterior axillary line getting ready to put the chest tube in and I’m standing behind Pete trying to figure out what happens next. I’m the senior surgeon in the room, closest surgical attending is maybe half and hour away and if we’ve got to do an emergent exploratory laparotomy it’s my problem and frankly I’d rather pass. It would be nice to think my conservative stance was on account of higher principles, a wish to spare homeboy a big midline incision, a lifetime of adhesions and a few days in house getting over his ileus but in reality I just wanted to get back to sleep. My two year old is not all that into sleeping and my wife nine months pregnant is not all that into not being grouchy. I’d been working all day and had to be in the OR all the next day. Yup, this was when things sucked but not in the “crap I’ll be home tonight at 5:30 rather than 4:30 and have to cut short my time at the gym” sucked, or in the “it’s so difficult to decide, should we ditch the kids and go to Santiago or London next month honey?” sucked, but in the “when will this **** end and how can I get another twenty minutes of sleep” way. Perhaps you can relate? Anyways, an unnecessary ex-lap might not be doing shot-guy any favors but it would ruin my night for sure. So when oxford-shirt-with-tie ER attending calls for a couple mg of morphine to be given IV to spare the patient a bit of discomfort from the chest tube insertion I say I’d rather skip it. Morphine can cause a transient drop in blood pressure and another couple low BP’s on the monitor and I’m obliged to open this guy up (and stay awake for another couple of hours) so I’d rather not have it on board confounding the situation.
Most ER guys differ to the surgeons, after all, they have only the haziest idea of what happens once the patient leaves the trauma bay, understand their limitations and sensibly stay out of the way. But this guy is different; he has his own ideas, probably went to a lecture recently on “pain being the sixth vital sign” or some such bull**** and he says “I’m going to give morphine.” This gets my attention, I explain, quickly, why this is bad idea. 3 minutes of pain from the chest tube insertion vs dropping the blood pressure and forcing my hand to do an exploratory laparotomy based on information confounded by narcotic is an easy decision. “Better not” I say. Unbelievably, he is not dissuaded, his team is looking on and he takes a stand. He tells me he’s the attending physician, he is board certified, he is in charge of this patient while the patient is in the ER and he is going to give the morphine.
It is at this point that certain things are alleged. The surgical team is on record that in calm and respectful tones their chief guided the care of the patient with a graceful firm and steady hand to it’s successful conclusion. Bless them. Meanwhile, the ER team over the ensuing days spilled a fair amount of ink all alleging this and alleging that. Something to the effect that allegedly the senior surgeon at the trauma told the attending emergency medicine physician in the white short sleeved oxford that each was the same amount of time out of medical school with the only difference between the two being that one had done a short residency and one had not. That the ER attending's lack of judgment was a threat to this patient, and that therefore the ER attending should get **** out of this trauma bay and find someone with an earache to treat before he hurt somebody. It is agreed upon by all parties that at about this point the ER attending dismissed the senior surgical resident from the case ordering the surgical resident to leave the area at which point it has been alleged that the senior surgical resident inquired as to weather said ER attending possessed the skill set to open the abdomen or chest and control an exsanguinating injury? Furthermore it has been alleged that the senior surgeon then pointed out that since dismissing the only person currently in the hospital with the ability to treat this potentially life threatening injury would be equivalent to murder, perhaps the ER attending should just go borrow one of the cops guns and shoot the patient himself and get it over with. It has also been alleged that the when the attending in the short sleeved white shirt, now bright red in the face, insisted that he was the physician in charge of the care of the patients in his emergency room and physically attempted to give the morphine via the IV, the senior surgeon in the room, who was six inches taller and 50 pounds heavier than him and had played a whole lot of college rugby positioned his body in such a manner to make such actions impossible and, it has been alleged, in doing so threw a body block that nearly knocked the ER attending over.
The chest tube returned nothing. The BP’s stabilized and later we learned that the gun shot wounds that we thought we were seeing were really fragments from the frangilble bullets that NYC cops use. These bullets are designed to break apart when they miss their target so as to cause minimal damage when they ricochet off things. The guy went home/to jail the next day.
With that trauma over the next one began. Young white-short-sleeved-oxford guy screamed for blood. He demanded dismissal of the surgical resident, he demanded that the medical board launch an investigation, he demanded formal sanctions, he demanded the senior surgical resident be banned from the ER. He got a lot of snickering from the Department of Surgery and a dripping letter of apology.
So why bring this up?
David Newman was the guy I had to push out of the way. He was a wanker then, he's a wanker now.
