Phallucies of trauma care (or, Getting shafted on night shift).

Iwas one of the first emergency medicine residents to fall into the clutches of our trauma service. At the time, the surgeons were intrigued and suspicious about this hokey new specialty of emergency medicine; therefore, they scrutinized my every move. Or so I thought. It was the glory days of trauma — the pre-Haldol, pre-sedation, big line, MAST pants era, when RSI meant Really Sweaty Intubation — the days when vocal cords were a moving target, and leather restraints and a security guard were essential intubation equipment. And the hospital had flare: there was a greasy spoon serving fries with gravy at midnight, and a burnt-out schiz living in a sleeping bag down near x-ray (you could call it that then). Rumour had it that his wife died during a routine operation and the hospital didn’t have the heart to kick him out. Either that or he was the surgeon who botched the job. I was fresh from medical school in New Zealand, armed with false bravado and an unusual vocabulary. I was two weeks into this “wonderful educational opportunity,” but the 1 in 3 felt suspiciously like 24:7. It was 11 pm Saturday night and I was feeling the heat. My problem was chest-tube envy. I’d done just about everything else with the 16-gauge needle and strong arm referred to in Shem’s House of God. Even burr holes hadn’t escaped me. But despite my eternal presence and steely nerve, a chest tube had not yet graced my latexed palm. And thanks to endless glib reminders from the senior surgical resident (SSR), this had become a standing joke with the attendings. Then suddenly it happened. The ED doors burst open and in came 4 sweaty paramedics pushing two 19year-old multi-traumas. After tuning out their ethanol-induced diatribes, I saw that their respiratory patterns suggested acute chest tube deficiency. I sprung into action. Moments later, after rapid primary surveys, I determined that they were indeed deficient, to the tune of one apiece. “The chest tubes are mine!” I screamed, as the trauma team burst in. (The trauma team, circa 1986, consisted of a family medicine resident, two rotating interns, a friend of theirs and a dermatology resident from Poland who was enduring his purgatory in the burn unit.) Frantically, I gathered my equipment and looked over at the saviour of my professional credibility — the soonto-be recipient of a virgin chest tube — who was now muttering rude remarks about my mother’s wardrobe and cursing the 68-year-old security guard sitting on his chest. The patient struggled gamely but the guard prevailed, despite advanced COPD and exertional cyanosis. With a sustained stridorous crow and a triumphant expectoration, he announced, “All yours, . . . (wheeze, hack) Doc! (cough, gasp).” Trembling but confident, I approached the bedside, armed with a number 15 scalpel and “the tube.” Before taking the plunge, I glanced over my shoulder to see what blessed souls would witness my pleural baptism. There, to my dismay, stood the senior surgical resident and two attendings — haggard and blood-stained after a 6-hour battle with an aneurysm. My fine tremor became coarse, and my resolve disintegrated as fast as my first episiotomy sutures. Nevertheless, I forged ahead. Scalpel through to the rib, tunnel up a space, pop through with the Kelly, a quick finger sweep, then in with the tube. Almost! My patient’s blood alcohol level of 67 was enough to slow but not block intercostal nerve conduction. Just as I was poised to advance the tube, his addled brain received the delayed but intense pain messages from his chest. He arched and screamed! “YOU TRUCKER!” (or words to that effect). Then he grabbed the bedrails and squeezed as hard as his muscular forearms could squeeze. Now it happened that I had lowered the rail and was hunched over the side of the bed, so that when he attempted to grab the bedrail, he in fact grabbed me. More precisely, he grabbed a tubular part of me that, at that instant, bore little resemblance to a bedrail. Then he squeezed. Hard. They say participants experience catastrophic events in slow motion. I don’t know about the future nuclear physicist lying on the bed, but for me, the moment was frozen right out of Shakespearean tragedy. It was a standoff — two gladiators locked in mortal Director of Emergency Medicine, Richmond General Hospital, Richmond, BC Received: June 13, 2000; final submission received July 9, 2000; accepted: July 10, 2000