“Doctor Wade, a gang dispute in East St. Louis has spilled across the river into downtown St. Louis. We’ve got several victims moving into the trauma bays. This guy’s been triaged to the top of the list.”
Sarah Wade, M.D. had a reputation in the E.D. for her cool and collected manner. She gazed at the twenty-something black male lying on his right side on the table, a knife embedded in his left chest, and took a deep breath, thinking through the ABC’s of advanced trauma life support: airway, breathing, and circulation.
“The scene wasn’t totally secured by police but the paramedics managed to scoop and run with this guy. Didn’t have time to deal with his airway or get I.V. access before hitting our doorstep.”
“Vital signs?” she asked.
“Pulse, 144. Respirations, thirty, short and shallow. Blood pressure, eighty systolic.”
“Get two large-bore lines started, normal saline …” She paused, remembering the Trauma Service’s penchant for lactated Ringer’s solution. “… make that LR and get blood for a CBC, chemistry panel, coags, and type and cross … six units of packed red cells to start.”
She surveyed the man, who showed no signs of movement. Even his chest wall appeared not to change with breathing. She would check him more thoroughly after completing the ABCs, but she predicted a Glasgow Coma scale of between 3 and 5. Not good.
“Get me a 7 and a half ET tube, check the cuff, and give me the fiber-optic scope. Get respiratory in here with a ventilator.”
Sarah’s friends assured her that next year’s Chief Resident’s slot was hers for the taking. And she wanted it. But right now, she had this ATLS certification to pass and her self-assurance ebbed as she nodded to the man sitting before her, his arms crossed, eyes glaring at her. Her heart rate accelerated and her gut grumbled. She knew him by more than reputation.
Doctor Robert Rickelmann. Internationally renowned trauma surgeon. “Roarin’ Robert.” The surgeon’s surgeon to whom residents-in-training were lesser mortals. As a first-year resident, she had experienced his trial-by-fire methods of “teaching,” the scorched scrubs and third degree burns he left behind on surgical rounds.
Doctor Rickelmann tapped his pen on the table, a look of impatience etched upon his face, and then waved his hand dismissively toward the bed. “Go ahead. Examine your patient. As you move from one system to the next I’ll provide basic details. You need to ask questions for information you don’t get from me.”
She continued, “While they’re getting venous access, I’ll prepare to intubate and check his cardiovascular status. His airway is …?”
“Light pink froth is noted in his mouth.”
As if on cue, crimson-tinged bubbles emerged from between the man’s lips. This guy’s good, she thought, continuing in clinical mode as if she was in the E.D. She pulled back the sheet, grazing the man’s cold forearm with her fingers. The moulage, makeup and props used to simulate physical injury, appeared more realistic than any she had seen before. A large plastic knife protruded from his chest several centimeters to the left of the sternum. She directed her “exam” to his lungs, but stopped as a droplet of “blood” escaped the wound. Can they make moulage do that?
“Absent on the left, coarse sounds on the right,” replied Rickelmann.
“I’ll yell for a STAT portable chest X-ray and proceed to intubate him.”
As if urged by an inner sense, she placed the diaphragm of the stethoscope to the man’s chest and listened.
“You see the knife … what’s the main thing you’re not going to do, doctor?”
The question and its answer, you don’t pull the knife until you’re ready to control the consequences, preferably in the O.R., registered at the edge of her consciousness. What captured her attention was the man’s lack of breath sounds. Sarah listened intently. How long could he hold his breath?
“Doctor? Your patient’s going down the tubes while you hesitate. What do you do next, and what do you make sure you do not do?”
Sarah reached to the man’s neck and tried to locate a carotid pulse. His skin here was also cool, with subtle mottling. Where was his pulse? Her hands rushed to the man’s face, pulling back the upper eyelids so she could take a quick look at his pupils. He didn’t flinch.
Roarin’ Robert was on his feet, his face reddened.
“Doctor Wade, this is a trauma scenario, not some damned ophthalmology quiz! What the hell are you doing?”
Sarah looked up at him, her usual assertiveness regaining control, the gastric butterfly gone. “No, Doctor Rickelmann, this is a real stabbing victim. Look, he’s not –”
“Nonsense. We were talking just an hour ago, before the lunch break. He was on call and worked all night. I told him he could sleep. Steven, wake up.” He took two quick strides toward the body, reached for the prop, but stopped short. “He –”
Sarah saw a brief look of puzzlement on the surgeon’s face, and did what no resident dared to do with Doctor Rickelmann; she interrupted. “Don’t Doctor Rickelmann! We need to call 911 and get him to the E.D.”
Sarah couldn’t believe the surgeon’s response. Did he think so little of her training that he ignored the obvious? All of his shouting would have awakened the dead much less any sleeper. This young man remained moribund.
He looked at her and frowned, shaking his head. “Crap, you work in the emergency department and can’t tell a fake wound from the real thing? Watch!” He grabbed the knife and pulled just before her hand caught his arm in an attempt to stop him. Startled by the sucking noise of air rushing into the chest, his face registered an apparition of shock when something more than a fake knife handle and plastic wound peeled away from the body. As blood covered his bare hand, he stood speechless and dropped both the stage prop and the disposable scalpel hidden within.
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