Last Night of Trauma Call

I recently completed my last night of trauma call . . . ever. The night had the usual assortment -- drunk, high, doped up, the not so brilliant decision makers, and the just plain unlucky. It brought back a lot of memories, and made me a little bit nostalgic.

There is something about being the trauma chief resident that changes you, and makes you different from most other doctors. When someone is deteriorating or even about to die, you have to make decisions very quickly. You learn that sometimes you do everything you can, and the person still dies -- its not your fault. You learn to break very bad news to families, and inevitably make the mistakes of painting a picture that is too optimistic or grim. You learn that you can't always be nice -- sometimes when the system isn't working smoothly for a patient who is in trouble, you have to find the source of the problem and perhaps rub someone's fur the wrong way.

The other thing you learn how to do is to perform the emergency procedures in surgery. That last night of trauma call, I thought back over some of the things that I had learned in the trauma bay. It was where I put my first chest tubes in. It was where I placed my first large bore central venous lines. It was where I learned how to quickly stop or control bleeding from major wounds, and also how to sew wounds up. It was where I had learned how to intubate patients. I had done several Emergency room thoracotomies there, in which you cut someone's chest open to diagnose and treat injuries to the heart, lung, etc.

However, in all of my 5 years of doing trauma, there was one procedure I hadn't ever done or even seen. On several occasions, I had a knife in my hand ready to do it, but at the last minute didn't need to. A cricothroidotomy (cric for short) is the way to obtain emergency surgical access to the airway. If a patient cannot deliver oxygen to his lungs, he will die. Establishing an airway is therefore one of our first priorities when evaluating a patient. This is preferably done by inserting a tube through either the nose or mouth into the trachea.

I had pretty much resolved myself to the fact that I might not do a cric during my residency. I felt confident that I could do one if needed. I had read the books, and could recite the technique. I had even taught courses to other people, and showed them how to do it on pigs. However, nothing is ever the same as being in a situation where it is you, a knife, a person who will die in a minute or so if untreated, and often a chaotic room full of people running around in circles.

My last night of trauma call was a busy one. There was a car wreck with several badly injured folks. There were the usual ATV/motorcycle accidents. In the midst of all of this, a patient was rolled back to the trauma bay with no advance notice to us. While I won't go into the details of his mechanism and injuries due to privacy laws, it very quickly became apparent that he wasn't going to be able to survive breathing on his own. The initial attempt at intubation failed miserably, and it was obvious that we would not be able to secure an airway this way. My attending and I decided it was time to cric him.

It went beautifully. We very quickly established an airway via a cric. The patient stopped acting like he was going to meet his Maker that day.

Although the entire night was busy, I left the next day feeling a sense of closure to my trauma experiences. There were no emergent procedures that I hadn't done at some point. I was ready to move on.