What’s more fun than a resident turning bright red?

A resident turning bright fuchsia!! Yeah!

Well, during one of my shifts at the trauma center, I got to have a little fun. It was just a regular ol’ night in the busy ED, yada, yada, yada. OK, OK, I’ll just get to the good stuff. We get a call on the EMS line for a 922 trauma (like a medium trauma – 911 means all hands on deck, major body parts missing and all that jazz). There’s a GSW to the right upper quadrant coming in.

I look at my resident, who is 3 months from graduating, and I point to him. “It’s all you, buddy.”

“Me?” he asks. “You got it,” I replied.

When I first got out of residency, I felt like I needed to establish my own comfort level with my practice before taking on residents full time. My personal feeling is that until you’ve been out in the middle of nowhere with a heart attack in one room and a woman coding in the next with little or no backup, it’s a little hard to explain to a resident what you would do if you don’t have every specialty on God’s green earth at your disposal.

I’m sure some people could spout out literature and sections of Tintinalli and Rosen from memory much better than I could, but my experiences in the last 3 years, working mostly by myself, have taught me so much.

It’s only in the last year or so that I’ve been more and more comfortable sitting back and letting residents take the lead. Emergency medicine residents from the UAB EM program do 2 months of a community rotation with us, and they always do a great job. But, as you know, the more confident you become in your own abilities, the more you can let go.

So as we are waiting for this trauma to come in, we hear this holler coming from the other end of the emergency department. “Get a wheelchair!” someone yells. “Oh, God. Oh, God!” another, deeper voice echoes.

A woman in green scrubs, whom I didn’t know (but later discovered it was one of the staff OB/GYNs), wheels a diaphoretic guy down the hall. He is dressed in a Burger King uniform and is extremely agitated.

“Is this the trauma?” I’m asking our charge nurse. “I don’t think so,” she says. She’s just as confused as I am. She sends someone to figure out what’s going on and security to make sure the place is secure. The area the man was wheeled from could only be accessed by someone with a name badge. Meanwhile, I send my resident into the room. “He’s been shot in the chest!” someone says.

It takes three or four large guys to get this guy on the stretcher. The patient is highly agitated. I made the universal sign for intubating someone (thumb down throat) to my resident. “That’s my plan,” he says.

In the meantime, the OTHER trauma arrives. The one we knew about. My resident wanted to stay with the first one, so I went to see the second.

This guy, though, with a GSW to the RUQ, had stable vitals and was talking. The nurse says to me, “Tetanus, Ancef, morphine, Zofran, fluids.” I nod. God, I love ER nurses.

So after putting in orders on both patients, I went back to see the progress on the other guy.

My resident had intubated the patient, got labs, a chest X-ray, started O-negative blood and everything! Wow! Except, his pressure was still 70/30.

I called our trauma surgeon and told him about our two customers. He said he was on his way.

“I think he needs a chest tube,” my resident said. True enough, that would be a first thought. There was a bullet hole right through the middle of his chest. But I wasn’t sure about that.

“I think you need to stick a needle in his heart.” Note the statement above. A bullet hole through the middle of his chest. “Let’s look at the chest X-ray.”

Pretty darn clear, no pneumothorax, and a bullet probably sitting in or next to the right side of the heart – causing pericardial effusion, thus causing tamponade, thus the hypotension.

Which led me to my next statement. “Get yourself a very long spinal needle and the ultrasound machine.”

As I was about to page the trauma surgeon to let him know that we were going to stick a needle in his patient’s heart, he walks in the trauma bay.

“Oh goody,” I said. “We were just about to drain a tamponade.”

He took a look himself with the ultrasound, and he agreed with that plan. Especially since the patient’s pressure wasn’t responding to blood and fluid resuscitation.

We attempted that, but the patient continued to crump.

Then our surgeon said the five magic words every EM resident dreams of hearing (especially when there are no surgery residents around). “Get me a thoracotomy tray!”

At this point, my resident turned red. Really red. The nurses all scrambled for the proper equipment and gloves for the three of us. The guy’s pressure was still 70/30. As the anticipation built, my resident turned fuchsia. He was finally going to get to do this. After 3 years of residency and jockeying for position with those surgery residents …

And then we looked up at the monitor and the pressure read 137/80.

The trauma surgeon, seconds from cracking this guy’s chest, says, “His pressure’s up! Let’s do this in the OR!”

Aw, hell. I know it’s better for the patient and all, but geez. We were so close.

They packed up our patient and rushed him up to the OR where they found a bullet chillin’ in his right atrium.

My resident and I stood in the empty trauma bay surrounded by bloody gloves and the trappings of a messy trauma. The color had drained from his face and he looked a little defeated. I turned to him and said, “I guess you fixed him a little too well.”

Looking back at things like this I kind of smile. I miss those days when everything was brand new. New procedures, new diagnoses, new everything. I still see new things every day, but when I get to work with the residents, it’s like watching the ED through a kid’s eyes. Maybe it’s kind of silly, but I think they keep me from burnout.

Our patient lived. He had a lot of operations and was in the hospital for more than a month. But about a week ago, he went home. Even though we didn’t get to do the cool procedure, we got to save this guy’s life. That’s also one pretty cool procedure.

Dr. Bundy is an assistant medical director at Baptist Medical Center East in Montgomery, Ala., and a former photojournalist, who not only sings in the car, but talks to herself, is addicted to diet drinks and shoes, and thinks emergency medicine is the greatest specialty.