Alone - A Novel - Chapter 2

Bleeding Out

Author’s Note

In Chapter 2 we take a step back, but not too far. Here we find Dr. Tom Powers in his element. I wanted to combine the absurdity of the scroll with the harsh reality for the trauma surgeon…in an instant the day changes from a few laughs over lunch or scrolling on Instagram to life and death. For Tom this is not the first time his scroll has been interrupted and it’s clear that he is becoming more and more distant. We see flashbacks to happier times or moments that remind him of his humanity, perhaps what he is losing, or what has been lost. Preparing for the dying patient Tom leads the room, is able to focus with clarity and accomplish his task; however, something is missing, the joy is gone, the job has become “problem and solution.”

As a surgeon I see joy being stripped from the profession of medicine and often notice it in my peers at the hospital. Frustrations expressed over coffee in the lounge or lunch in the cafeteria. As in everything, an effect typically has many causes, it is far more complex than binary and so the solutions become equally difficult. Doctoring requires empathy and compassion, but what happens when that deteriorates in the caregiver?

If you haven’t had a chance to read Chapter 1, please check it out and let me know wha you think.

A man sits peacefully with his morning paper on the toilet of a cozy winter cabin when suddenly a fawn crashes through the adjacent window followed by a grizzly bear in hot pursuit, shattering the silence. The frightened man rockets off the seat and out of the bathroom, pants around his ankles.

Swipe up.

A young boy catches the quick attention of his Florida parents riding across the lawn on the spine of an alligator.

Swipe up.

An idiot quietly bends down to remove a quill from a cornered porcupine instantly finding his entire body, from forehead to fingertips, covered in defensively released, barbed quills. The man faints and falls off the porch.

Swipe up.

Mr. Rogers sits with Easy E, laughing on his couch, both clutching a bottle of 40 oz malt liquor, “Easy…you like Botha?” “Botha?” Mr. Rogers offers the crude punch line.

It has to be AI but damn, that’s funny.

The sterile hum of the fluorescent panel light fills the small, airless room. In the corner, a computer station beams blue light from an unfinished progress note over to Tom, entranced by his scroll on the disheveled single bed. He blinks, and is brought quickly back to the reality of his blank-walled sixty-square-foot cell by a piercing alert from his pager, clipped to the front of his scrubs next to his ID badge, his portrait yellowing from years left in the center console of his F-150 between shifts. Tom unclipped it and held up the pager with a feeling of familiar resentment. The thing was indestructible. It had fallen off of a cliff while mountain biking, dropped in the pool by his youngest and even thrown against the wall, once, maybe more, but each time it came back buzzing. He wished the same could be said for everything else. Tom was convinced only a plunge into the toilet and a forceful flush could kill it.

“CLASS 1 30Y/O M GSW ETA 8 MINUTES”

Class 1. Life or death, again.

The text hit like a shot of adrenaline. Thirty-year-old male with a gunshot wound, 8 minutes out. Tom slid the pager back into its clip, closed his eyes, and exhaled slowly, for another second he enjoyed the peace and solitude of his small prison. He swung his legs over the bed and slipped into his blue Calzurro clogs, appreciating the stimulating bumps on its footbed. Tom grabbed his phone, heavier than a phone should ever need to be, and slid it into his back pocket. The weight tugged at his waistband, pulling the scrubs off Tom’s slim frame. He untied and retied the pants tighter. Heading out into the brighter fluorescent hallway, Tom grabbed his white coat off the door and walked down the short corridor connecting the call rooms to the trauma bay. Two nurses in a panting jog passed him en route, “Morning Doc” they both said between breaths. Just morning. The witching hour for gunshot wounds, bar fights turn to stand-offs. Pride and alcohol conspire to summon a trigger pull, the likely story for the young man unconsciously racing toward the emergency room doors. Nearing the trauma bay, Tom could hear Dr. Jameson’s gravelly voice echoing from residency: Don’t run. Walk. Think. Tom always thought of the worst, knowing that the solution for the most feared problem would likely prepare him for anything else.

Chest tray, left thoracotomy, Lebsche knife, clamshell possible, remember the phrenic, prolene, pledgets.

Tom flashed his badge on the wall sensor and the opening doors revealed a rush of activity. There were no smiles, just familiar faces focused on their task. Tom hung up his coat. The blood from an hour ago was gone, only clean epoxy-resin reflecting the bright lights above.

“Can we get everyone together for a quick time-out? Four minutes away now.” Tom asked Jesse, the charge nurse walking quickly through the trauma bay. “And who’s the ED doc on today?” He added before she could reply.

“It’s Dr. Singh, I’ll grab everyone.” Jesse responded, walking out of the trauma bay and into the emergency department.

Over the next few seconds, nurses, techs and doctors filled the room, each grabbing a yellow fabric gown, blue gloves and a few adding eye protection. Tom took off his wedding ring. Turning over the worn ring in his fingers he could hear her laugh and for a moment was transported. He took off his bracelet and watch, placing the watch band through his wedding ring, a habit so practiced it no longer felt like a ritual. The beads on his bracelet spelled D-A-D, the original bright neon colors now faded from years of hand sanitizer, all three safely placed together in his left front pocket.

“Dr. Powers, two minutes.” Said Jesse from the hallway, snapping Tom back to the present. Hating how easily he could be torn out of a moment, Tom put on his own yellow gown and blue gloves and stood in a commanding position at the end of the empty gurney, freshly cleaned, wheels locked, ready to support its next victim.

“Alright, everyone quiet down, Jesse, what do we know?” Tom asked.

“30 year old male coming from scene after two gunshots to the chest, unresponsive, no vital signs, CPR in progress.” She said directly.

“Ok, Rich, you’re on airway and I saw Dr. Jones with anesthesia just coming down the hallway for backup. CPR is ongoing so we’re going to open up the chest, let’s get that chest tray ready. I want 36F chest tubes available and bilateral upper extremity IVs. Jesse, do we have blood in the room and the level 1 infuser?” Tom rattled the plan off as he had clarified it on the walk in, a plan he has rehearsed and executed hundreds of times. There was a flurry of activity opening up the sterile equipment for the thoracotomy on the left side of the gurney, a spread of instruments and a large chest retractor ready to crank open the ribs and expose the heart and lungs.

“Have you seen Ryan?” Tom asked, referring to the chief resident on the trauma rotation who was perpetually late and a source of great resentment.

“If he rolls through the doors with a fucking coffee in his hand I’m going to lose my shit.” Tom said as he noticed one of the techs pulling over the ultrasound machine for a FAST exam. “Hey, get that thing out of here, this guy is dead right now, we don’t need it, make space.” Time ticked away and the room began to take shape.

At the head of the bed, Dr. Rich Singh, an experienced and confident ER physician was prepared to secure the airway. Next to him respiratory therapy set up the ventilator. Two nurses, one on each side of the bed, prepared to get intravenous access. Dave, an x-ray tech Tom had known since his days as a resident rolled in and parked himself and his large portable machine toward the back of the room, out of the way but ready to pop in when needed.

“Get some paint out, prep the chest as soon as we transfer him to the bed, we’re going to go fast.” Tom directed Sara, the nurse on the bed’s left side. Hastily she opened the wet prep and set it within arms reach.

“Blood is in the room.” Commented a runner from the back, coming through the trauma bay doors with a large cooler full of blood products. At the same moment Eric, one of the scrub techs came in, his bold red, white and blue American flag scrub cap was what Tom noticed, giving him a sense of calm and confidence.

“They’re here,” spoke another tech, standing in the hallway with her arm out to keep the trauma bay doors from sliding shut.

The gurney came rushing through the ER entrance, a paramedic straddling the patient, his arms locked compressing the chest repeatedly. Blood covered his gloved hands, sweat dripped from his forehead. Another paramedic squeezed the Ambubag, delivering breaths and oxygen. The wheels rattled over the floor as they made a sharp left turn, swinging into the trauma bay.

“Let’s get him on the bed. Get blood ready to transfuse on the level one. Give me the report.” Tom said to the two medics, one climbing off the dying patient.
“Adult male, two gunshots to the chest, lost vital signs on scene about, 11 minutes ago, we scooped him up. No IV access. No meds given.” Replied the breathless medic, lifting the patient on the spine board and transferring over to the gurney.

“Dr. Singh, secure the airway, let’s check a pulse, Sara prep the chest wide.” Tom motioned to the ER resident who began working to place a chest tube into the right chest. A nurse slammed an IV in the left antecubital vein and began pushing blood rapidly into the patient. A code dose of epinephrine is delivered into the second IV. At that moment, Ryan came into the trauma bay and entered Tom’s peripheral vision, a wrinkled white coat over wrinkled scrubs and coffee in hand.

“God damn it Ryan, run this trauma while I open the chest.” The anger came easily these days, it was the only thing that cut through the fog. Tom moved quickly from the foot of the bed over to the patient’s left, grabbing a 10 blade off the tray and in a single efficient swipe from sternum to the bed opened the patient’s skin down through the adipose tissue to the rib. Holding the gaping wound open with his left hand Tom entered the thoracic cavity with scissors, cutting the intercostal muscle off the top of the rib. Tom pushed the scissors back with intention, the muscle peeling off with the sharp instrument, dark blood welling up through the opening, spilling over the patient’s cool skin and onto the floor. Tom pushed the jaws of the chest retractor over the ribs and into the patient and cranked the chest open. The soft, pale lung, bellowing with each breath delivered by Dr. Singh squeezing the Ambubag was the first thing Tom saw as he turned the lever. As the heart came into view Tom could see the pericardium bulging, huge like a dark balloon ready to lift up and out of the chest, a small hole leaking dark blood.

“Rich, I need you to take over running this Trauma, Ryan, put on a gown and gloves and give me a hand.” Tom said, his eyes focused. The heart, suffocated and squeezed to death with each beat by the blood and clot gathering around it in the inelastic pericardial sac, like a pebble in a giant’s hand, needed to be released.

“Get me pickups and scissors, load up a double armed 3-0 prolene on a pledget and have it ready, Ryan, here.” Picking up the tight pericardium, Tom took the scissors in his right hand and opened it. As he lengthen the incision, each centimeter released the deep purple clot hiding the heart beneath. Tom scooped off the dark crimson jelly and revealed a small, pale, quivering heart, dying as the moments passed. The injury became clear, a gash through the thin right ventricle. Tom handed back the scissors “give me that prolene” he said, eyes fixed. Into the operative field his right hand brought the driver, directing its needle across the wound. After a couple of bites, Tom tied down the knot, squeezing the pledgets at wound’s edges together, closing the hole. Despite the repair, the empty heart laid flaccid, without a beat.

“Keep pushing volume.” Tom yelled, his hands now enveloping the heart and squeezing it rhythmically to get blood out to the brain, body and heart itself through the coronaries. Seconds and then minutes passed and in a moment, feeling like the heart was pulling the rhythmic energy right out of Tom’s hands, it took over. “We have a heart beat. More volume.” Tom watched as the heart began to pick up its pace. The room exhaled, a hushed “yes” could be heard in the crowd. For the team it felt like a resurrection, a dead patient brought back to life, for Tom it was the machinery of life turning over again.

“Youth is on his side. Let’s go up to the operating room and complete the exploration. Does he have any family here?” Turning to Jesse.

“No one.” She said.

It was over in less than 10 minutes and the patient was at least temporarily alive. Tom stripped off his gloves, the mineral smell still clung to his hands, as it always did, long after the soap.