When the Air Hits Your Brain: Tales from Neurosurgery

6. Ailments Untreatable

At the university hospital, the days belonged to pain, the night to trauma. Our hospital was a “level I” trauma center, able to handle virtually any type of trauma except the most severe burn cases, which were diverted to the burn center across town.

There are two places where a body loses its human facade, where the trappings of personality, intelligence, and spirit fall away to reveal the Frankenstein mechanism of arteries, veins, and nerves beneath. One is the autopsy table. The other is the trauma room.

It was another night on call. I had retired to the spartan house-staff quarters on the hospital’s uppermost floor to grab some sleep before facing the next day’s overloaded operating schedule. The on-call room was little more than a hard bed and a loud phone. The doors didn’t even lock—the legacy of a previous hospital administrator who feared that locked doors would mean too much sex among the house staff. The little that administrators do know about medicine must be garnered from daytime television. Soap opera M.D.’s may fornicate in the linen closets, but the average surgical house officer would more likely be caught sleeping there.

The emergency room awakened me at two in the morning with word that an ambulance carrying an auto crash victim was pulling in. Before heading down to the ER, I stopped in the bathroom. Any patient too ill to wait for me to pee was likely to die with or without my help.

I entered the trauma room just as a pale and bloodied young woman was being lifted from the ambulance stretcher onto the trauma room gurney. She was strapped to a “backboard,” a wooden platform used to immobilize the entire spine. A paramedic in a blue jumpsuit droned her report to all within earshot: “Caucasian female, age twenty-two…unrestrained passenger in a car traveling at high rate of speed down Bigelow Boulevard. The car crossed the center line and collided with another vehicle. Victim was found awake but incoherent outside of the vehicle. Blood pressure 100 over 60, pulse 125. An open laceration in the right frontal parietal area was packed to stop bleeding. Large blood loss was apparent at the scene. No obvious limb fractures or deformities were noted. The patient moves all four extremities spontaneously, but follows no commands…”

Fearing that more trouble was on the way, I asked the paramedic what had happened to the other victims of the crash.

“Two people in the other car were taken to Mercy Hospital,” she replied, adding under her breath, “and the driver of her vehicle was dead at the scene. We pronounced him and called a coroner’s ambulance.”

“You pronounced him?” I asked with mock indignation. Officially, only a licensed physician can make the pronouncement of death.

“It doesn’t take an M.D. to know when a headless guy is dead,” she answered with a slight smile. I still had a lot to learn about street trauma. The paramedic crew retired to the front desk to complete their reports and await the return of their backboard.

Nurses quickly cut the clothes from the injured woman’s arms and torso. Until the extent of spinal injury is known, excessive movement of the patient is unwise and the more civil methods of removing clothing are too dangerous. For those with minor injuries, watching a beloved sweater being shorn from their bodies like fleece from a sheep can be more traumatizing than their accidents. The victim’s lower body was encased in a blue MAST suit, a comical set of inflatable pantaloons used to force blood from the expendable legs into the not-soexpendable head.

I donned a pair of latex gloves and removed the gauze pads the paramedics had stuffed into the head wound. Pulling away blood-caked hair, I separated the edges of the lacerated scalp. The wound was eight or ten inches in length and filled with road dirt and fragments of windshield glass. The glistening ivory surface of the skull showed; a jagged fracture ran parallel to the laceration. Pink, macerated brain tissue the consistency of toothpaste leaked from the fracture line.

The Edwin Smith papyrus, an ancient Egyptian medical text dating back to 1700 B.C., declared that any patient with brain tissue oozing from a skull fracture had “an ailment untreatable.” Nearly four thousand years of medical progress had not disproved this grim prognosis.

I ruffled through the papers stuffed under the backboard, searching for her first name…Shirley. Under normal circumstances I would never address a new patient by her first name. Such uninvited familiarity is the province of car salesmen, not physicians, but a severely head injured patient requires a less polite approach.

A first name is the most durable lifeline to the outside world, the first word recognized and the last word forgotten. When a dementing illness erases our awareness of home, spouse, and children, we will still answer to our first name. A first name can pierce the delirious fog of head trauma faster than any other word. Leaning close to her face, I smelled her alcoholladen blood—a nauseating aroma unique to emergency rooms.

“Shirley,” I spoke directly into her ear. She slowly opened her eyes.

“Yes?” she answered, her voice muffled by the green plastic oxygen mask draped over her mouth.

“Shirley, my name is Frank. You’ve been in a car accident and you’re in the hospital. I don’t think you have been badly hurt, but we have to do a bunch of things here. It’s going to be a long night. Can you wiggle your toes and fingers for me?”

After a brief delay she obeyed, feebly, and then closed her eyes again. Although I was encouraged that she was not unconscious, I remained skeptical about her chances for survival. I had seen “talk and die” patients before, those who have a short period of wakefulness followed by a slow descent into coma and brain death. Just as a sprained ankle may not bruise and swell until hours after being twisted, the injured brain may not succumb to edema until several hours after a lethal impact.

The skull is a best friend and worst enemy to the gelatinous organ within. During normal daily activities, the brain sways to and fro in a watery sea of spinal fluid, tethered to the bone by small veins. During rapid acceleration and deceleration, such as during a car crash or during the vigorous “shaking” of a crying infant (one of the leading causes of infant murders), the brain slams into the skull and rips loose from its venous moorings. Blood oozes from the torn veins, forming compressive clots known as subdural hematomas, while edema fluid collects in the bruised areas of the brain. Trapped within the skull’s bony confines, the swelling brain chokes off its own blood supply and strangulates. In a trauma, the skull turns from a brain’s protector to its murderer, and, finally, to its coffin.

The surgeon can intervene by removing blood clots and giving drugs to reduce brain swelling, but the damage is often irreversible. Surgeons in Japan tried removing the top of the skull in these patients, allowing injured brains unlimited space in which to swell. The skull’s “lid” was stored temporarily in a refrigerator, to be replaced when the swelling subsided. In some cases, unfortunately, the brain swelled to monstrous proportions, making the patient’s head look like something from a bad science-fiction movie. The patients died anyway and the practice has been abandoned.

In desperate cases, large sections of the brain can be hacked away to make room for more swelling—a kamikaze strategy. In a macabre sense, Shirley was performing this type of surgery upon herself by squeezing her swollen brain tissue through the open skull fracture. The continuous decompression of dead, liquefied brain matter from her wound may have been the only thing keeping her alive at the moment.

“Shirley, you have a cut on your head from the windshield and this young doctor is going to put some stitches in your head.” I instructed the general surgery intern to suture the laceration using a quick layer of running nylon. Since I was likely to reopen the wound in the operating room in a few hours, a cosmetic closure was unnecessary. “It doesn’t have to be a Rembrandt; just stop the bleeding. And try to keep her hair out of the wound.” He grimaced at the sight of a growing mound of brain exuding from the wound. I wiped it away with a gauze sponge. “Memories of third grade,” I whispered, “but don’t let it bother you; she won’t miss it.”

Bill, the senior surgical resident, examined the woman’s chest and abdomen while his junior residents performed other standard chores: drawing blood samples for the lab, inserting large intravenous lines, feeling along her arms and legs for any palpable fractures or lacerations, debriding the skin of dirt and glass.

“Type and cross her for six units of blood,” Bill instructed a trauma nurse, “and see if they can send down some type O in case she crashes. What’s her pressure now?”

“Ninety over sixty.”

“Force in another liter of lactated Ringer’s as fast as you can and get the X-ray people in here.”

I called the CT technician to let him know that we needed an urgent brain scan. A physician must wake up a lot of people in the middle of the night and attempt to engage them in meaningful conversation.

“Hello,” a dreamy voice answered.

“Are you the CT technician on call?”

“Hello?”

“IS THIS THE CT TECH ON CALL?”

There was a pause and the rustling of bedsheets. Christ, I thought, he’s falling asleep. The previous month, a tech had dropped the phone on the floor while I was talking to her and gone back to sleep. I had to send the police to get her.

“…Uh, is this the hospital?” The tech was barely conscious.

“No,” I replied, “it’s Ed McMahon calling you from Publisher’s Clearinghouse. You have just won one million dollars. And, by the way, I’ve got a trauma here in the ER and I need a scan now.”

“OK.”

It wasn’t a convincing okay, more like the okay of someone who was slipping back into slumberland, to awake in four hours wondering if the hospital had really called or if he’d just had a nightmare. I called again ten minutes later and was informed by his irate wife that he indeed was on his way.

Perhaps I was a little rude, but I didn’t care. I now knew how James Bond must feel when he thinks he’s saving the world from certain destruction. Politeness and civility are sacrificed without a trace of guilt. As the earth teeters on the brink of nuclear holocaust, Bond runs through a crowded airport knocking people flat, kicking over their luggage and spilling their drinks—all without so much as an “Excuse me.” He’s not rude; he’s a hero on a mission. He can grab people by the throat, hold a gun to their heads—anything to get the job done. I can say: “Get your ass out of bed and scan this lady BEFORE SHE DIES.” In the end, all is allowed, all is forgiven. We do what we have to do. Results, not effort.

Shirley’s blood pressure began to rise and stabilize. The intern had finished closing her scalp and the X-ray technicians were setting up to take chest, neck, and abdominal films.

“Shirley, are you still there?” I asked.

“Yes, but my head hurts. Am I going to die?”

“No. Too much paperwork if you die. We’re going to take some X-ray films.”

“How’s Jack? I want to see him.”

“Uhmmm…he’s not here right now. They took him someplace else.” A diplomatic response. She was in no condition to learn that her friend had been guillotined. Bill and I retreated to the small coffee lounge, where we feasted on a box of vanilla wafers stamped “For Institutional Use Only.” I had gained twenty pounds in three months on the boss’s service from eating vanilla wafers washed down with chocolate milk and was becoming an “institution” myself, at least in terms of body habitus. The coffee was a day old, but we drank it anyway for its medicinal properties.

“This is just fucking great,” Bill complained. “I have a Whipple to do tomorrow and I’m going to be totally fried. We get a Whipple about twice a year.” An operation for pancreatic cancer, the complicated Whipple procedure was something that the general surgery residents slather over.

“At least you may be able to go back to bed soon,” I countered, “but she’s got the gray matter coming out of her head. She’s going to need a craniotomy if she doesn’t croak first. And the boss has all four of our OR’s booked at seventhirty. If he gets bumped by this case he’ll blow a fuse.”

I glanced at my watch. It was now three-thirty. My mind turned to those bureaucratic dilemmas which consume so much of a resident’s time and energy. There was no way I was going to get Shirley scanned and complete a craniotomy fast enough to avoid delaying the boss in one of his rooms. Tomorrow was his squash day, too. If he wasn’t done by noon it would be me who’d need a craniotomy. And who was going to cover my room if I was in the OR with this case? I could put the intern in my room, but that would piss off the boss. He’d go bananas on the intern, and then the intern would hate me for the rest of his neurosurgery rotation. Tuesday was always our biggest day. Why did these cases always roll in on Monday night? Who went out drinking and driving on a Monday night?

I could ask anesthesia for a fifth neurosurgery room. I could ask Mother Teresa for a date, too; the answer would be the same. I glanced over the OR schedule tacked to the bulletin board. Four heart rooms, four ortho rooms, four neuro rooms…it was hopeless. They’d never give us five rooms. I had to either bump one of the boss’s cases to a later time or cancel one altogether. I pulled out my patient list, called the neuro nursing station, and spoke to Karen, the night charge nurse.

“Karen, this is Frank. Is there any excuse for canceling one of the seven-thirty cases tomorrow, like a fever, a low potassium—anything?”

“Let me look.” There was a pause as she went off to review the charts. “Well,” Karen returned, flipping pages, “Mr. Jamieson’s potassium is 3.5.”

“Not low enough.”

“How about Mrs. Bates, the hemifacial spasm,” Karen continued, “her temp at midnight was 99.7.”

“Not high enough. Has everyone signed consents? Doesn’t anyone have any doubts? Maybe someone needs an extra day to think about their surgery? It is brain surgery, after all.”

“No chance. These are the boss’s patients, remember?”

“Yeah, right. If you think of anything let me know. I have a trauma down here who is about to fuck with our elective schedule.”

I crammed my patient sheets back into my coat pocket, finished my coffee, and returned to the trauma room, where Bill was already reviewing the chest film.

“Her mediastinum is a tad wide,” he murmured to me. “She’ll need an aortogram.”

The aorta, a gargantuan artery which carries blood from the heart, descends between the two lungs on its way to the abdomen in a chest space called the mediastinum. In the mediastinum, the aorta is tethered by a short ligament called the ductus, the remnant of the embryonic artery which shunts blood away from our fluid-filled fetal lungs. In the rapid deceleration of a car crash, the ductus acts as the aorta’s seat belt, restraining the jumbo artery’s midsection while the rest of it continues to move forward at great speed. In a violent crash, even a young and resilient aorta can tear and leak blood into the mediastinum, widening the space around the heart as seen on chest X rays. A leaking aorta, like a leaking dam, can burst at any time. For Shirley, an aortic tear meant that her great blood vessel would have to be replaced with a Teflon tube before a terminal hemorrhage occurred.

Shirley was now the typical “multiple” trauma. With at least two of her vital organs in need of surgical repair, we had to decide which organ took priority. Was it better to have a new Teflon aorta transmitting blood to a worthless brain, or a good brain in a body dead from aortic rupture? We hadn’t even tapped her belly—what surprises lurked there?

Although it was possible to operate on the brain and chest simultaneously, the thoracic surgeons would have to “thin” Shirley’s blood with the anticoagulant drug heparin during the time her damaged aorta was clamped. Otherwise, the stagnant, nonflowing blood would clot off in her aorta. Anticoagulation made brain surgery out of the question. The brain is the bloodiest organ in the body, and any attempt to manipulate it without the body’s clotting mechanisms in full working order would be a lethal exercise. I decided that if she needed both brain and chest operations, they would have to be done separately. I just hoped her belly tap was clean.

A belly tap is made just below the navel: a thin tube is inserted into the abdominal cavity through a tiny incision. Sterile saline is injected, swished around, and aspirated. If the fluid returns tinged with blood, then a spleen rupture or liver laceration is likely. Yellow, turbid fluid indicates a bowel injury. A junior surgical resident began painting Shirley’s abdomen with orange Betadine solution, while a nurse unwrapped a belly tap kit and placed in on the Mayo stand beside him.

“Shirley, are you still there?” I asked.

“Yes.”

“She was sleepier, more distant. Her left hand grasp was weaker. Worrisome. Her head was going bad faster than I had planned. The scanner people would be here soon. Bill was on the phone to the angio people, arranging a dye test to look for the suspected leak in Shirley’s aorta. With the possibility of a growing intracranial clot, however, she might not last the one or two hours necessary for an aortic angiogram. I would be forced to take her to the OR without it. Of course, Bill would object and we would have one of our frequent fights over which organ system needed attention first.

I reached Dr. Sakren, the attending neurosurgeon on call, and notified him of the situation. His political weight might bully the thoracic surgeons into letting us work first. Sakren was less than enthusiastic—“Call me back if you really need me”: code language for “Deal with it yourself, I’m sleeping.” Thanks a bunch.

That’s why people go to university centers: in search of first-year neurosurgical residents to make their life-and-death decisions for them. I was hoping for more moral support from the attending, but calling him again could be construed as unmanly. In a neurosurgical residency, one of the last maledominated bastions of medicine, looking unmanly is almost as bad as looking lazy. I let him sleep.

Shirley’s belly-tap fluid came back crystal clear—the abdominal organs had escaped major damage. Had Shirley been wearing her seat belt, her injuries would have been reversed. Instead of shattering the windshield with her head when ejecting from the car, she would have crushed her lower abdomen against the belt, perhaps lacerating her small intestine. In any violent collision, something in the body must take the impact force, something must give. Intestines can be repaired. Fixing the brain is much harder.

The rest of Shirley’s X rays had been developed and delivered to the trauma room. The neck and lower-back films disclosed no fractures or dislocations. I released the straps on her bulky vinyl cervical collar and allowed her to be moved from the backboard. The board was quickly wiped clean and returned to the paramedic crew, who had finished their paperwork and were anxious to get back on the road.

I told the operating room that an emergency craniotomy was brewing, they should set up a brain instrument tray. The night charge nurse gave me the usual grief about the liver transplant that was still going on, the heart patient who was oozing from his chest tubes and might have to “come back,” the open fracture from three hours ago that ortho was still trying to get on the schedule. It was the same story every night I tried to do a case.

“Don’t the transplant people ever work during the day? What are they, vampires? Look, I don’t really care what’s happening up there; just set up a room now.” That James Bond feeling again.

“All right, we’ll set up in one of your morning rooms. You’ll have to bump one of Abramowitz’s seven-thirty retromastoids.” There was a “nyah-nyah” tone in her voice. She knew that bumping his cases carried a risk of castration.

“Can’t you put me in one of the general surgery rooms? We’ll be out by nine or nine-thirty, I promise.” Really, Mother Teresa, you’ll have a wonderful time…I know a place, great Indian food…

“No way. Don’t get greedy. With the backup of cases from last night, you’re lucky we don’t take away another one of your rooms, too, so be thankful you still have four start times. What time will you be up?”

“The scanner people should be here soon. I guess thirty minutes.” It was actually going to take an hour or more to get to the OR, but they didn’t need to know that.

Bill had overheard my conversation. “What about my aortogram?”

“Sure, Bill, if there’s time.” (No way, my friend. Brains first, big bloody hoses second.)

“We have to make time.”

“If the angio people are here, we’ll take her right from CT to the angio suite, and then to the OR. But she needs a craniotomy before she gets her chest cracked.” No matter what the scan showed, the skull fracture would have to be cleaned out and any bone fragments or hair driven into the brain removed.

“Fine.” Bill seemed satisfied with the compromise. “But I want to see that aortogram. If she’s dissecting we have to do that as soon as you’re through.”

True enough, but an aortic dissection would really blow my OR schedule to hell. To get a new aorta, Shirley would be in the neuro room until two or three in the afternoon, meaning that two or more of our elective patients would have to be canceled outright, not just delayed. Holy shit! I didn’t even want to think about that. I pulled out my patient sheet again. Who would it be? The Italian businessman who’d flown halfway around the world for his operation? Nope, he stays on the schedule. The wife of the director of a major metropolitan opera company? Abramowitz had some big hitters in the day’s lineup. No one would go quietly. Please, Shirley, have a good aorta.

I suddenly felt very tired. The next day’s work loomed ahead. I could envision each burr hole I would have to drill, each scalp stitch I would have to place, each small brain bleeder I would have to coagulate. Hundreds of tiny motions and I didn’t feel like doing any goddamned one of them.

The trauma room’s intercom buzzed. “The patient’s parents are in the waiting room,” the desk clerk informed us. As bad as I thought my night was, this family’s night was going to be worse. To me, she was as much a bureaucratic nuisance as she was a patient. To them, she was a first step, a first word, a first bicycle, a first date. Decades of their lives, a fond tapestry woven of birthday parties, summer vacations, proms, and graduations, was shredding apart in our ER. The baby they’d tossed into the air now dripped her brains into four-by-four gauze sponges. Bill and I went out to talk with them. Medicine at its ugliest.

The middle-aged couple remained sniffly but stalwart throughout our presentation. Bill discussed the need for a dye test to check the main artery in her body and the possibility that the artery might have to be repaired surgically. I discussed the nature of her head injury and obtained their consent for the brain surgery. They asked the usual questions about her chances for meaningful survival, what she would be like, had her face been badly damaged, and could they see her before she went to surgery. I dodged the recovery issue, stressing that she had suffered no obvious cosmetic damage and was not in severe pain. Doctors are like politicians: we stress the good things. Since we were doing all we could as rapidly as we could, I doubted that there would be time for her parents to talk with Shirley before she went to the scanner.

For her family, this was a nightmare of biblical proportions. Pulled from a sound sleep into a dim ER waiting room and forced to listen to the planned dissection of their daughter, these poor people could not have been encouraged by our appearance. With our five o’clock shadows, uncombed hair, and iodine-stained lab jackets, we must have looked like high school students to them, right down to our soiled tennis shoes.

I put my hand on the mother’s shoulder, saying that I would be back when I knew more. We returned to the trauma room. The heavy metal door clanked shut, sealing off the waiting room from our brightly lit inner sanctum. A nurse was disconnecting Shirley’s heart electrodes from the wall monitor and hooking them to a portable monitor/defibrillator perched on the end of her bed. A respiratory technician attached Shirley’s oxygen mask to a small green tank. The scanner was ready and they were preparing her to be transported from the ER.

The scanners were in the adjoining children’s hospital, one flight up and about two hundred yards away from the trauma room. The operating rooms were yet another flight up, and another two hundred yards away from the scanners. When transporting an unstable patient, even a brief elevator ride and short roll down a hallway can be an unsettling experience. Surgeons feel comfortable only in the operating room. The operating room sits in a virtual sea of specialized instruments, resuscitation equipment, and anesthesia expertise. Field trips to radiology were like moon walks, the patient tethered to a precarious lifeline of battery-powered monitors and small scuba tanks of oxygen, far from an anesthesiologist and a good instrument set.

“What’s her pressure doing?” Bill asked.

“Ninety over fifty,” replied a nurse.

“I’m not happy about transporting her until we hang some blood. Is there blood in the room?”

I examined Shirley again. Brain matter still oozed from the sutured scalp laceration. “Wiggle your toes.” This time she wiggled only the toes of her right foot. “Wiggle the toes of your left foot.” Again the right foot. She was developing some paralysis on her left side. At this rate, it was only a matter of time before she started talking about bright lights beckoning her to “cross over to the other side,” or some other hallucination common to dying brains.

“We need to scan her,” I told Bill.

“The blood’s here,” he argued back. “It’ll take just five minutes to hang a unit on a pump bag. Her hematocrit’s only twenty-eight, she’s had seven liters of fluid, and her pressure’s falling again.”

“What’s happening to me?” Shirley cried suddenly as she reached up to pull the oxygen mask away with her remaining good arm. Jan, one of the night nurses, grabbed her arm and told her to relax.

“But I can’t breathe!” she cried hoarsely as she began to struggle with the nurse, jerking with her right arm and twisting her head grotesquely from side to side. I looked at the portable heart monitor. Her heart rate, which had been about 120 for the last hour, had jumped to 190.

“Pressure,” Bill ordered.

“Seventy over palp.”

“Get anesthesia, stat. She’s going to need a tube. And get me a chest tray and call the cardiothoracic fellow down here.”

I knew what Bill was thinking. Shirley was no longer losing blood from her scalp and her belly tap showed no evidence of abdominal bleeding. The falling pressure must be due to blood escaping from the rending aorta in her chest. Her inability to breathe was a sign that her chest was filling with blood, crowding her lungs. Her heart was pumping furiously to make up for the decreased blood volume. She was “shocking out.” Opening her chest and clamping her aorta right there might be her only chance of survival. Anesthesia would have to insert a endotracheal tube and put her to sleep. If they didn’t arrive in time, Bill would do it with her awake.

Nurses and aides darted from other ER rooms, helping to ferry messages to the front desk. In addition to the anesthesiologist and cardiothoracic fellow, the attending trauma surgeon was notified, and the operating room. Two floors up, the OR technicians began putting away the cranial drills and brain retractors and began setting up the heart-lung machine and chest instruments. An ER medical resident came in and helped Bill insert another IV line. One of the other senior surgical residents on call had arrived and was unwrapping the ER chest tray and preparing some chest tubes, long plastic hoses that are inserted into the chest to drain blood and air. The doors to the other ER rooms were closed to shield the few other patients from the unfolding spectacle.

I remained at the head of her bed. Shirley’s eyes were wide open, her pupils unequal. She was panting in brief, labored breaths; her color had turned ashen. Jan handed me an Ambu bag, a device used to assist the patient’s breathing. I removed the oxygen mask and firmly pressed the Ambu over her mouth, squeezing the bag hard to drive in air. “I’m dying, I’m dying,” she gasped between squeezes.

She was right, she most certainly was dying. We have an innate ability to tell when something is lethally awry in our bodies. My father had chest pains for years before his first heart attack, but we could tell from his face on the morning of that first attack that this pain was different. There was panic in his eyes. Physicians don’t get concerned about patients’ asking if they are going to die, but when a patient blurts out “I’m dying!” we know that this is often an accurate prediction.

The nurse-anesthetist and anesthesiologist came bustling into the room carrying a large tackle box full of laryngoscopes, endotracheal tubes, and anesthetic drugs. The nurse-anesthetist displaced me at the head of the bed and began squeezing the Ambu bag. “I can’t ventilate her,” she said to the anesthesiologist. He quickly handed her a laryngoscope, which she snapped open like a switch blade. It had a long silver spatula with a light at the tip, which she inserted into Shirley’s mouth. At the same time, the anesthesiologist injected a combination of curare-like drugs and narcotics into one of Shirley’s many intravenous lines. These drugs would paralyze and sedate her so that she would not fight the efforts to breathe for her.

The nurse-anesthetist cocked Shirley’s head back and pushed the steel blade deep into her throat, lifting her tongue away so that the entrance to her windpipe could be seen. Shirley coughed and retched violently on the scope’s blade, straining against the cloth restraints that tied her right arm and leg to the stretcher. The curare finally took effect and Shirley’s struggling ceased. “I see the cords. Give me a tube.” The anesthetist was staring at Shirley’s vocal cords. She was handed a clear plastic tube coated with petroleum jelly, which she slipped between the vocal cords into Shirley’s windpipe.

I stepped out of the room and watched from the hallway. Over a dozen people filled the small room now, and I was the most dispensable of the lot. Since Shirley was under general anesthesia, I could no longer follow her brain function. Her skin color deteriorated further, to the pasty yellow-blue hue of a cadaver. “Pressure fifty over palp.” The EKG monitor showed runs of ventricular tachycardia, the heart’s equivalent of “throwing a rod” from being pushed too hard. Her tank was running dry.

Bill and the cardiothoracic fellow, who had just darted in, took off their lab coats and put on sterile gloves as the intern poured a bottle of Betadine onto Shirley’s exposed chest. The respiratory therapist, a large man with muscular forearms, attached the Ambu bag to the endotracheal tube and squeezed hard. Even with the tube in place, his strong hands could barely force air into Shirley’s collapsing lungs.

I knew this flurry of activity was nothing but a dance of death for poor Shirley. Her aorta had burst, spilling blood into her chest. Like a jetliner with its hydraulics destroyed, her body was still flying but had no hope of landing safely. In a few minutes her life was going to come thundering to the ground in ER room eight.

Bill plunged a number 10 scapel blade to the hilt in her chest wall and cleaved a twelve-inch window under the left breast. As he entered the pleura, the thick leathery covering of the lung, a huge glob of clotted blood slithered out and splattered to the floor. The cardiothoracic fellow jammed a rib spreader into the wound and cranked it open, splaying open the chest cavity as rib bones cracked and popped. I continued to observe for a while as the two men muttered to each other, passing their arms, bloodstained to the elbow, in and out of the chest wound. They held back the foamy pink lung as they probed with long metal clamps and needle holders. The thin, purple blood continued to flow unchecked out of the wound and onto their clothes and shoes.

Shirley’s blood pressure collapsed. Her tracing on the monitor writhed chaotically as the heart’s rhythm degenerated into fruitless quivering and fibrillations. An alarm sounded from the monitor—it was the sound of my OR schedule becoming whole again. The cardiothoracic fellow reached deep into the chest and grabbed the heart, manually massaging the flaccid ventricles. “Empty,” was his simple pronouncement. She was gone. He withdrew his arm, removed his gloves, and went to the sink to wash.

“Will you talk with the family?” I called in to Bill, who nodded grimly as he continued to stare into Shirley’s chest. Thank God. I could just imagine those poor people sitting out there watching the parade of people rushing into the ER. I’d told her mother I would be back. I’d lied. This was a trauma surgery death, not mine. The general surgeons could play the grim reaper on this one.

In the OR, the chest instruments were being repacked and the room readied once more for Dr. Abramowitz’s first patient. An irate CT technician, his night disturbed for no good purpose, was shutting down his computer. Unused blood was packed up and trundled back to the central blood bank to await the next disaster. The angio people were going home. The small medical army drafted for this war was quickly demobilized. The cleanup people were summoned. Bill assigned the hapless intern the task of closing the dead woman’s chest. “It doesn’t have to be a Rembrandt.”

On this night I had the singular honors of hearing a woman’s last words, of denying her parents the right to see her alive one last time, and of permitting her to die believing that her boyfriend was still alive. Eight floors up, seven people on the neurosurgical OR schedule were sleeping, unaware that, for a few hours, I had been rearranging their futures in my head. As it turned out, their surgeries would go on as planned and the boss would play his squash.